Not meeting expectations: A qualitative study of feedback from program directors about residents who did not meet performance expectations.

PURPOSE: The AAMC's Resident Readiness Survey (RRS) is administered to program directors (PDs) nationally about their postgraduate year-1 (PGY-1) residents and provides feedback to medical schools about their effectiveness in preparing graduates for residency. The authors sought to characterize the factors contributing to a PD's assessment that a resident had not met expectations. METHOD: Using 2023-2024 RRS data, the authors performed a qualitative analysis of free text responses from PDs regarding residents who were evaluated as "did not meet overall performance expectations." The authors independently coded those comments using conventional content analysis to describe the categories of comments present. Using a recursive approach, they iteratively discussed and refined their codes until achieving consensus. RESULTS: On the RRS, 431 PGY-1 residents were evaluated by PDs as not meeting expectations (2.9% of 14,641 completed surveys). Of these 431 residents, 309 residents (71.7%) had comments available for analysis. Categories for PDs' comments corresponded to challenges in five competencies with identified subcategories for each. In addition, professionalism and practice-based learning and improvement were identified as mitigators of challenges in other domains. PDs also provided comments about potential reasons a resident was not meeting performance expectations, including limited clinical exposure in medical school, inadequate identification by the medical school of performance issues, or a lack of communication to residency programs about those issues. CONCLUSIONS: PDs' comments described challenges of PGY-1 residents in five particular competencies, highlighting alignment between national competency frameworks for undergraduate medical education and how PDs view resident performance. The findings also highlight opportunities to improve the transition ecosystem, including enhanced student assessment in undergraduate medical education and improved communication to residency programs about medical school graduates' strengths and areas for continued growth and development.