Abstract
Objective To determine which non-clinical elements should be included in the transition-to-practice curriculum of a residency training program.
Data sources A rapid review was conducted following Cochrane methods guidance using a predefined registered protocol. MEDLINE was searched and studies reporting on transition-to-practice curricula published in English were included. Manifest content analysis was used to identify and report the frequency with which various transition-to-practice curricular elements appeared in the literature. Grey literature, non-English studies, and those reporting on nonphysician health professionals were excluded.
Study selection A total of 40 articles met inclusion criteria. Most (92.5%) were from North America.
Synthesis The most common study design was a survey (42.5%), followed by focus groups (12.5%) and semistructured interviews (12.5%). The most common non-clinical themes of transition to practice were financial and administrative aspects (37.0%), followed by personal well-being and work-life balance (21.0%), career planning and professional development (16.0%), and interpersonal skills and professional behaviour (16.0%). Other topics included legal knowledge related to medical practice (6.9%) and scholarly aspects of independent practice (3.8%).
Conclusion Medical residents face a steep learning curve as they transition to independent practice. This study identified the most frequently discussed areas of training in non-clinical transition to practice discussed in the literature. Inclusion of these ideas into a dedicated transition-to-practice curriculum could support family residents as they move into independent practice. Further research should seek to evaluate the most effective ways to teach these elements, to identify elements specific to family medicine residency, and to explore learning opportunities for early-career physicians.
Medical training is characterized by many transitions as trainees rotate through various disciplines. These many small transitions are punctuated by 2 major ones: first, when medical students become resident physicians, and second, when residents become autonomous physicians. These transition periods are challenging and can cause substantial stress and burnout.1 Also, uncertainty and a perceived lack of preparedness can cause new physicians to avoid certain aspects of practice, for example, they may stop providing obstetric care.2
Although increased attention has been paid to the transition-to-practice period in many specialties,3-6 a number of factors render the need particularly urgent for family medicine (FM). In FM, residents have the shortest training period—2 years in Canada, 3 in the United States. Additionally, family physicians face a high level of complexity in patient care compared with other specialties.7 This complexity could further result in new physicians narrowing their practices if they feel unprepared.2 Aside from the clinical uncertainty new physicians face, they must also navigate other aspects of independent practice, such as office management, billing,8 and teaching.9 In 2022, the College of Family Physicians of Canada published a position statement calling for renewal of the FM curriculum.10 In their report, they emphasized the transition-to-practice period, among other things, and called for improved support for soon-to-graduate and recently graduated physicians. This improved support could help physicians build clinical confidence in areas of uncertainty. Furthermore, it would allow physicians to strengthen their teaching capacity, build leadership skills, and more readily help advance the discipline of FM.
To guide educational endeavours around the transition to practice, some specialty programs have generated learning outcomes.4 However, none have yet been formalized in FM. To provide a foundation for a transition-to-practice curriculum that could meet the particular needs of FM residents, we reviewed the literature and asked the following question: From the perspective of learners and faculty members, which non-clinical elements of the transition-to-practice period should be included in an FM residency curriculum?
METHODS
While performing this review, we referred to the guidelines published by the Cochrane methods group,11,12 and adhered to the Rapid Review Protocol as outlined by Virginia Commonwealth University.13 We followed a predefined registered protocol for this rapid review (International Prospective Register of Systematic Reviews: CRD42024545186). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting checklist was used in the preparation of this manuscript.14 Because this study did not involve humans, no ethics approval was required.
Identification and selection of studies
A professional health sciences librarian helped refine the search strategy to ensure thoroughness and precision. Key terms included transition to practice, early career, and internship or residency to narrow both topic and population. The complete search strategy is reported in Supplemental Table 1, available from CFPlus.* Our initial search was run between February and March 2024, with an update in September 2024.
We limited our search to MEDLINE and included only English-language studies published in 2010 and later. We included studies from any specialty that reported on any of the following: transition-to-practice educational interventions, programs, curricula, surveys, and qualitative interviews. Included studies focused on residents, fellows, or early-career physicians. Grey literature and non-English articles were excluded. Studies discussing the transition to practice for nonphysician health care providers were excluded.
Articles identified in the initial search underwent title and abstract screening by a single screener (A.S.). To mitigate potential bias, a second reviewer (S.F.) independently reviewed 20% of the same texts. The 2 authors compared the dual-screened texts to achieve 100% agreement. A.S. independently screened full texts using the Covidence platform to track the screening process.15 S.F. reviewed all excluded abstracts as well as the full texts that had been selected.12 Data were then extracted from the final included articles. The results extracted by A.S. were shared with S.F. for discussion. The 2 article reviewers resolved any disagreements during the screening phase through discussion. If consensus could not be reached, a third team member (K.J.T.) was consulted to resolve the discrepancy. For the search update, S.Z. and S.F. each conducted the abstract and title review for half the articles. S.Z. then completed the full-text review and data extraction. S.Z. reviewed those articles marked for full-text review and resolved any questions with S.F. Because our primary objective was to map themes from the literature, and because of guidance from Cochrane12 and others,11 we chose not to conduct quality appraisal on the extracted articles.
Data analysis
After identifying the included articles, A.S. applied a deductive coding strategy, grouping important transition-to-practice ideas by themes. S.F. and S.Z. reviewed and finalized all themes and codes, referring to the corresponding articles. Because gender data were not readily available for all included articles, and because our study did not focus on gender, we did not extract gender data. To extract observable ideas, A.S., S.F., and S.Z. coded articles using manifest content analysis.16-21
We collected descriptive data, including country of origin, specialty, and study type (Table 1). We used an inductive approach to content analysis and for the development of categories for themes and codes. Because a single study can give rise to multiple codes, some articles in this review contribute to multiple themes. All authors reviewed the developed content categories.
Study characteristics: N=40.
SYNTHESIS
The identified articles (N=1662) were screened for eligibility by A.S., S.F., and S.Z. After we removed duplicate articles and screened titles and abstracts, 132 records were left. After full-text review, 40 unique articles remained (Figure 1).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram
Most studies were conducted in North America (n=37), 9 of which took place in Canada. The remainder were conducted in Europe (n=3). The majority were descriptive in nature (n=31), and surveys were the most common study type (n=17). The remaining studies (n=9) were interventional, the most common intervention involving the implementation of a curriculum or program (n=4; Supplemental Table 1, available from CFPlus*).
Six themes emerged from the literature regarding the transition to practice for a variety of medical specialties (Table 2). For each theme, multiple ideas coded from the literature generated subthemes, with some articles contributing to more than 1 subtheme or theme.
Identified themes and subthemes on transition to practice: Total occurrence of codes and number of unique articles are given with citation numbers indicated.
Theme 1: Financial and administrative aspects of working as a physician
Codes regarding familiarity with the business aspects of working as an independent physician emerged as necessary for a smooth transition to practice (n=48). The most frequent code was practice management (n=13),5,22-33 followed by financial management and literacy (n=12),5,6,22,23,26,29,33-38 the fundamentals of billing and coding (n=11),23,25,26,28,29,31,33-35,37,39 business management (n=10),22,25,27-29,31,33,34,37,40 and medical documentation (n=2).33,39
Theme 2: Personal well-being and work-life balance
This overarching theme addresses the challenges physicians face in managing their careers while maintaining personal health and achieving work-life balance (n=27). The 2 most common codes were mentorship (n=6)5,6,24,41-43 and time management (n=6).24,25,33,43-45 Other elements included leadership (n=3),24,46,47 strategies to maintain work-life balance (n=5),5,22,33,48,49 finding a job (n=3),25,33,35 well-being (n=3),45,48,49 and professionalism (n=1).47
Theme 3: Key aspects of career planning and professional development
This theme covers key factors that support physicians’ professional growth (n=21). Contract negotiation emerged as a prominent subtheme (n=8),22,23,25,26,31,33-35 with career planning similarly common in the literature (n=8).4,5,22,25,33,35,43,50 Other elements of this theme included networking (n=3),25,43,51 continuing professional development (n=1),5 and professional autonomy (n=1).51
Theme 4: Interpersonal skills and professional behaviour
Our findings also indicate a focus on learning competencies related to interpersonal skills and professional behaviour (n=19). Conflict resolution (n=5)24,30,46,47,52 and leadership skills (n=5)22,30-32,36 emerged as the key areas in this theme. The subthemes of teamwork (n=4),22,24,47,53 communication skills (n=2),36,46 self-awareness (n=2),46,47 and professional behaviour (n=1)54 were observed in the literature.
Theme 5: Medicolegal knowledge
Our results show that for early-career physicians, it is valuable to know about the legal system insofar as it interacts with medical practice (n=9). Our findings show that most research in this area centres around medicolegal education (n=6),4,6,23,33,36,55 medical malpractice (n=2),35,56 and regulatory compliance (n=1).35
Theme 6: Scholarly aspects of independent practice
Of the 6 themes that emerged from our review, this one appeared the least often (n=6). Codes include academic productivity (n=1),45 lifelong learning (n=1),57 and balancing research and clinical practice (n=1).49 Other subthemes were related to teaching medical learners (n=1),24 training in supervision and assessment (n=1),58 and providing feedback (n=1).47
DISCUSSION
In FM research, few articles elucidate the period of transition from residency to independent practice. Our review identifies 6 non-clinical themes that can help residents in the transition period. Here, we will discuss our results in the context of the 2-year Canadian FM residency, and emphasize potential considerations for curriculum developers.
Considerations within the family medicine context
FM residency is the shortest residency program in Canada; this brevity presents challenges in clinical, administrative, and academic spheres. If we compare the leadership opportunities embedded in the Royal College of Physicians and Surgeons of Canada (RCPSC) programs to those offered by FM residency, we see a discrepancy: While senior residents in 5-year RCPSC programs are often responsible for leading team huddles, teaching junior learners, and managing workflow, the same cannot be said of senior residents in FM programs.59,60 In FM, this senior resident model does not exist; therefore, learning to teach, manage teams, etc, often happens after graduation. Gallagher et al have pointed to the need, and appetite, for more training so that FM residents can take on leadership roles in their careers.24 Some residency programs (outside FM) have attempted to outline the necessary components of a transition-to-practice curriculum.58,61 To tailor our findings to the Canadian context, national transition-to-practice priorities could be established through consensus-building techniques. However, for FM programs to successfully incorporate transition-to-practice elements into residency, they will need to consider not only topics covered in this review but also gender-specific concerns and the local context (eg, provincial payment models).
Transition topics to consider
While our review highlighted 6 non-clinical themes, we will discuss the 2 most salient of these: First, financial and administrative aspects of working as a physician, and second, personal well-being and work-life balance.
Financial and administrative aspects of working as a physician was the most frequently coded theme in our review, highlighting the importance of this topic. The need to master tasks such as reimbursement processes,23,25,26,28,29,31,33-35,37,39 financial planning,5,6,22,23,26,29,33-38 and general practice management,5,22-30,32,33 underscore the many administrative skills required to effectively manage a practice. As Gianakos et al62 found in their study, many residents feel unprepared to handle financial matters, which is also linked to increased stress and anxiety. Residents have a strong desire to have financial literacy included in residency curricula.62,63 Certain programs have approached this issue by implementing workshops run by financial experts37 or by faculty volunteers.34 These curricula have shown statistically significant improvements in resident knowledge and interest in financial aspects of practice.5,22-30,32-34,37 A comprehensive financial literacy education, including debt management and loan repayment, can substantially reduce stress, improve physician well-being, and contribute to long-term professional success.
These outcomes constitute the second most common theme: personal well-being and work-life balance. This theme includes codes such as mentorship5,6,24,41-43 and time management24,25,33,43-45 with skill development in these areas helping physicians navigate new leadership responsibilities.24,46,47 The work by Hernandez-Lee and colleagues reaffirms our findings by noting that formal mentorship programs offer valuable support to residents through networking opportunities, career coaching, and increased confidence in personal and professional success.64 The opportunities offered through mentorship not only guide mentees in shaping their career paths but also promote self-directed growth. Mentorship is most effective when the partnership is assigned or well matched through structured programs and in consideration of career and personal goals.41-43 Several factors can impact such programs. For instance, positive impacts have been seen when residents are given autonomy in choosing a mentor.41 Simply having mentors available can improve the residency experience and influence career decision making.42 Time constraints faced by both mentors and mentees can limit the effectiveness of programs and should be considered when implementing this element in a transition-to-practice curriculum. Further research could try to identify the most effective way of incorporating formal mentorship into existing residency programs.41-43
While we discussed the 2 most commonly occurring themes identified in our review, curriculum developers should consider many aspects of the transition to practice in order to support physicians’ professional growth. These numerous non-clinical skills, such as communication,36,47 teamwork,24,53 and leadership22,30-32,46,47 are also sought by residents to help prepare them for the complex roles they will take on in practice.
Limitations
The main limitation of this review is the dearth of literature on the transition to practice for family physicians. While many similar transition challenges exist among non-FM specialties, the short residency for FM imparts certain challenges for graduates. Additionally, literature cited in this review is from multiple jurisdictions. Concerns surrounding remuneration and billing, for example, may differ from place to place. Finally, in keeping with common practice with rapid reviews, we did not conduct a formal quality appraisal.11,12 This limits evaluation of the methodological rigour for individual studies and should be acknowledged as a potential limitation of the review.
Conclusion
New family physicians face many hurdles in the first years of clinical practice,2 including learning non-clinical aspects of medical practice. Our review takes a systematic approach to outlining the educational themes on the transition to practice commonly emphasized in the literature. While some other specialties have looked at how to incorporate transition-to-practice elements into their training programs, little has been reported for FM. Our structured review, though it draws from non-FM specialties, can serve as a foundation for curriculum planning in this area. Future research could build our understanding of the transition-to-practice period in FM and explore the impact of different educational interventions.
Footnotes
↵* Supplemental Table 1 is available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.
Contributors
All authors contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
- Copyright © 2026 the College of Family Physicians of Canada
