Transition to Residency at Large University Teaching Hospital in Egypt: A Qualitative Study of Surgical and Emergency Medicine Residents

ABSTRACT

Background

The transition to residency (TTR) is a critical and challenging phase for medical graduates, particularly in specialties like surgery and emergency medicine (EM). There is limited research exploring the experiences of residents in resource-limited non-Western settings.

Objective

To explore how surgical and EM residents at a university hospital in Egypt perceive, navigate, and respond to the multifaceted challenges of the TTR within a clinical environment characterised by limited resources and high demand.

Methods

A qualitative descriptive study using directed content analysis, guided by Schlossberg’s 4S transition framework, was conducted during the 2024-2025 academic year across multiple campuses within a large, university-affiliated hospital system in Egypt. Purposive maximum variation sampling was employed to include residents from various hospital locations, surgical specialties, and training levels. Semistructured interviews and focus groups were conducted by the primary researcher. All data were analyzed deductively using ATLAS.ti software.

Results

A total of 20 residents from 4 Alexandria University hospitals participated in the study, including 10 general surgery residents (specializing in gastrointestinal/hepatic, head and neck, ophthalmology, and orthopaedic surgery) and 10 EM residents. Data were collected through 12 semistructured interviews and 2 focus groups, each with 4 residents. Transition experiences were heterogeneous and shaped by gender and workforce dynamics. High physician turnover and staffing shortages in tertiary care settings increased the pressure on residents in their early roles. Organizational, peer, and family support were key in overcoming these challenges.

Conclusions

In resource-constrained settings like Egypt, individual and systemic factors shape the TTR.

Introduction

The transition to residency (TTR) is an important milestone in a medical trainee’s career, representing a challenging stage during which newly qualified physicians adapt to demanding clinical environments.¹ TTR is often characterized by steep learning curves, long working hours, and heightened emotional stress, particularly in high-intensity specialties such as surgery and emergency medicine (EM).^2,3 Although the TTR has been widely studied, most of the available research originates from high-income contexts and focuses on domains such as preparedness for practice, educational and organizational strategies, and the quality of orientation programs.^4,5 Little is known about how residents experience this transition in contexts with limited resources, where systemic factors such as culture, workforce dynamics, physician turnover, and restricted organizational support may influence these challenges.⁶ Addressing this gap is important not only for developing contextually relevant strategies to support residents in low- and middle-income countries but also for enriching global medical education scholarship by incorporating underrepresented perspectives.

Challenges in TTR include increased cognitive and emotional demands, the abrupt role shift of taking on unfamiliar clinical responsibilities, navigating unfamiliar institutional systems, policies and workflows, and learning new organizational structures.^6,7 Therefore, multiple interventions have been implemented to support residents, including structured near-peer mentorship and coaching programs,^8-10 residency preparation courses,¹¹ and organizational strategies that provide orientation, feedback, and tailored support.^6,12,13 Evidence from the literature shows that building relationships with peers, supervisors, and the wider health care team fosters a sense of belonging and provides essential emotional and professional support.^14-16

Residency programs worldwide share core elements, such as clinical training and progressive responsibility, but they differ in duration, curriculum, and research opportunities according to national and institutional priorities.^17-19 Training typically spans 5 to 7 years for general surgery and up to 8 years for subspecialties such as neurological surgery and orthopaedics.^20,21 Programs in the United States and Europe commonly integrate clinical rotations, didactic instruction, and simulation-based training.²⁰ In the Middle East and North Africa region, including Egypt, residency programs broadly align with global models but are shaped by local institutional and regulatory factors. Most are hospital-based, competency-based, and require completion of research projects or theses.²² In Egypt, medical graduates may enter postgraduate training immediately after completing undergraduate education, which traditionally followed a 6-year competency-based medical curriculum and a 1-year internship (house officer training) of supervised rotations across major clinical specialties. Recent reforms have replaced this model with a 5-year undergraduate program followed by a 2-year internship; however, no cohorts from this system have yet progressed to residency training, and only about 20% of graduates ultimately enter structured specialty programs, while the remaining 80% practice as general practitioners.²³ There are 2 primary postgraduate training pathways in Egypt as explained in Table 1.²³ Challenges facing Egyptian residents include inadequate supervision, vague job descriptions, insufficient practical training, and limited involvement in program evaluation—prompting many to consider changing specialties or seeking qualifications abroad due to concerns about training quality and clarity.^24,25

Table 1.

Comparison of Residency Training in University Hospitals and the Egyptian Fellowship (Board)

Aspect	University Hospitals (Master’s Program)	Fellowship of the Egyptian Board (FEB)
Training model	Academic and research-oriented	Professional and competency-based
Regulatory framework	Ministry of Higher Education and Research University–specific regulations	Ministry of Health and Population regulated national board program
Qualification awarded	Master of Science (MSc) degree	Fellowship certificate
Average duration	∼5 years (specialty-dependent)	∼4 years (specialty-dependent)
Educational orientation	Academic training integrating clinical practice and research	Clinical training focused on competency attainment
Coursework requirements	Mandatory completion of academic coursework	Specialty structured clinical curriculum
Assessment methods	Written, practical, and clinical examinations; master thesis defense	Continuous workplace-based assessment and final board examinations
Entry criteria	Minimum graduation grade	Completion of compulsory service in a primary health care unit

The aim of this study is to explore how surgical and EM residents experience and interpret the TTR within Alexandria University Hospitals, a large, tertiary care center in Egypt. This study conceptualizes the TTR, not only as the initial months of training but also as an early adaptive process that begins upon entering residency and continues as residents adjust to new clinical responsibilities, professional identities, and workplace demands. This broader perspective enables the exploration of immediate transition challenges and residents’ retrospective reflections on how these experiences evolve over time.

KEY POINTS

What Is Known

Organizational and workforce factors likely influence how residents adapt to the transition to residency. However, most existing studies focus narrowly on preparedness and orientation in high-income contexts, leaving little understanding of how gender, culture, and systemic pressures shape experiences in less resourced settings.

What Is New

This qualitative study of Egyptian surgery and emergency medicine residents examined how gender, language, workload, safety concerns, and limited institutional support influenced their transition. The residents relied heavily on their peers, interprofessional teams, and self-directed learning, with some adopting avoidant strategies, such as planning to leave their training programs or migrate.

Bottom Line

Transitioning to residency in resource-limited contexts requires more than individual resilience. Organizational support, gender-sensitive policies, and attention to workforce dynamics are also essential to safeguarding residents’ well-being and sustaining the health care system.

Methods

Study Design and Setting

Grounded in social constructivist epistemology, this qualitative study explored residents’ transition experiences as shaped through social interaction with peers, supervisors, and workplace structures, reflecting the constructivist assumption that meaning is created through engagement with one’s social and cultural environment.²⁶ This epistemological stance closely aligns with our research aim to understand how contextual, relational, and organizational factors shape TTR.²⁷ Data were collected between February and August 2025 across multiple sites of Alexandria University Hospitals, one of Egypt’s largest academic medical centers.²⁸ Purposive maximum-variation sampling was used to ensure diversity across key dimensions, including hospital site (Azarita Main University Hospital, Smouha Emergency University Hospital, El-Hadara Hospital, and University Students Hospitals); surgical specialty (general surgery and specific surgical fields) and EM; gender; and stage of training (early and late residency across the 5-year residency program).^27,29 Residents were eligible to participate if they were enrolled in a surgical or EM residency program at one of the participating hospitals for all 5 years of training. Exclusion criteria included working in nonclinical roles, being on extended leave, and being affiliated with the Egyptian board program. Initial recruitment was carried out through announcements on social media resident groups, followed by snowball sampling, whereby participants referred colleagues who were eligible and interested, drawing from a total resident population of roughly 100 across the participating sites.

Qualitative Data Collection, Transcription, and Translation

The data collection approach combined focus groups and semistructured interviews due to the logistical challenges of organizing focus groups among busy professionals, as documented in the qualitative literature.³⁰ The first author (M.S.) conducted the data collection in Arabic (the participants’ native language) via Zoom, using a discussion guide developed from the transition literature. The guide was piloted with one resident to ensure clarity and relevance before data collection, translated accordingly, and is provided in the online supplementary data. All sessions were audio-recorded, and the recordings were transcribed verbatim. Sample quotations selected for publication were translated into English by the author (M.S.). A professional translator reviewed these translations but had access only to the anonymized quotations included in the manuscript. The data were organized and coded using ATLAS.ti software (GmbH).

Qualitative Content Analysis

This qualitative exploratory study employed a directed content analysis approach, starting with the Schlossberg’s 4S model as the guiding framework for deductive analysis.³¹ The 4S model conceptualizes transitions through 4 interconnected dimensions: (1) self, which includes personal characteristics and psychological resources; (2) situation, which includes the circumstances related to the transition; (3) support, which includes external resources such as family, peers, and institutional structures; and (4) strategies, which include the coping responses. The 4S model is a widely used framework in transition research because it provides a comprehensive structure for understanding how individuals interpret and respond to major life and role changes. It was particularly suited to this study as the TTR is shaped by a combination of personal, social, and organizational factors. The 4S model enabled us to systematically explore these dimensions while paying attention to context-specific influences in Egyptian clinical settings.

Following the main stages of qualitative content analysis, we began with decontextualization, where the first author (M.S.) divided the transcripts into smaller units and coded relevant key phrases and concepts. The coding was based on 6 interviews and 2 focus group transcripts, after which no new relevant insights were emerging, reflecting a point of saturation and indicating information redundancy and sufficient information power for the analysis.³² During the recontextualization phase, the second author (A.S.) reviewed the initial codes to confirm their accuracy and ensure that the data’s meaning and context were preserved.³³ In the categorization phase, the authors (M.S., A.S.) clustered related codes into themes to identify patterns within the data, and in the compilation phase, relationships among themes were examined to generate conclusions and insights, with codes iteratively revised and refined. Throughout the analytical process, the 2 authors regularly reviewed the coding and interpretations, and discrepancies were resolved through discussion and negotiation, reaching a consensus.³⁴

Reflexivity and Positionality Statement

The research team acknowledged how their professional backgrounds and positionalities influenced the study process. All interviews and focus group discussions were conducted by the first author (M.S.), a physician and lecturer in medical education and an experienced qualitative researcher, with no prior relationship with the participants. Her outsider position facilitated openness and candor in participants’ responses, although it may have limited shared contextual understanding. The second author (A.S.), a professor of surgery and director of the compulsory internship program, deliberately refrained from participating in data collection due to potential power imbalances related to his senior institutional role. He contributed to the analysis of anonymized transcripts, ensuring that his expertise informed the interpretation while minimizing his influence on the participants during data collection.

Ethics

This study was reviewed and approved by the Ethics Committee of the Faculty of Medicine at Alexandria University (serial number 0307125; date of approval February 9, 2025). Participation was voluntary, and all residents were informed about the study’s objectives and their right to withdraw at any time without consequence. Written informed consent was obtained prior to data collection. To ensure confidentiality, all transcripts were anonymized, and all identifying information was removed. The data were stored securely and accessed only by the research team. All participants who gave their consent completed the data collection process, and there was no attrition.

Results

Participants

A total of 20 residents participated in the study, representing various specialties, training locations, and stages of training, ranging from the first month of residency to having just completed residency (Table 2). Twelve semistructured interviews (n=12) and 2 focus groups (n=8) were conducted. The interviews lasted between 24 and 39 minutes, while the focus groups lasted 46 and 53 minutes, respectively.

Table 2.

Demographic Data of Study Participants

Category	Participants N=20
Gender ratio
Men	9
Women	11
Specialty group
Surgery	10
Emergency medicine	10
Surgical specialties, N=10
General surgery (gastrointestinal/hepatic surgery, head and neck surgery)	7
Ophthalmology	1
Orthopaedic surgery	2
Hospital locations
Azarita Main University Hospital	10
Smouha Emergency University Hospital	4
El-Hadara Hospital	1
University Students Hospital	5

Coding Framework

The final coding framework was composed of the 4 dimensions of transition according to Schlossberg (Table 3).³⁵

Table 3.

The 4 Dimensions of Transition Adapted From Schlossberg³⁵

Theme	Subthemes	Description
Self	Preparedness/unpreparedness for practice, roles and responsibilities, gender and personality traits	Self explores participants’ sense of readiness for independent practice and the expansion of their roles and responsibilities. It also explores how gender and personality traits influence adaptation to residency.
Situation	Working conditions, postgraduate career paths, labor market conditions, and safety/exposure to violence	Situation explores the structural and contextual factors that shape the transition, including workload intensity, staffing shortages, mandatory academic requirements, career trajectories, and threats to personal safety.
Support	Interpersonal (peers, senior colleagues, and family), interprofessional, and institutional support	Support explores the formal and informal support systems including peer and near-peer relationships to supervisory, family, interprofessional, and institutional resources.
Strategies	Individual, institutional, and interprofessional collaboration strategies	Strategies explores the coping mechanisms that participants employ as well as institutional and interprofessional practices that can mitigate stress and foster adaptation.

Self

This theme explores personal characteristics relevant to the transition experience and includes the subthemes of preparedness/unpreparedness for practice, roles and responsibilities, and personal factors such as gender and personality traits (online supplementary data Table A). Participants expressed mixed views about their preparedness for clinical duties and the emotional demands of residency. Some felt adequately prepared and informed, facilitating a smoother transition, whereas others described a marked gap between expectations and the physically and emotionally draining realities of practice. This disparity influenced their self-confidence and early adaptation, often generating fear and self-doubt.

There was a consensus among study participants that the TTR was a turning point marked by a fundamental shift in roles and responsibilities. Several described the change as abrupt: while house officer training offered structured and protected learning, residency required independent decision-making and responsibility for outcomes. This shift was accompanied by increased workload and time pressures. The frequent use of “my patient” signaled growing professional autonomy and emotional investment.

Individual characteristics, particularly gender and personality traits, shaped how participants perceived their roles, interacted within teams, and were perceived by patients and colleagues. Some viewed gender as a barrier to professional acceptance, especially in patient and family encounters, while others emphasized that clinical competence is not gendered but grounded in individual attributes and behavioral skills. For some women participants, predominantly male environments hindered social integration and collegial relationships.

Situation

This theme explores the external and contextual influences on the TTR and includes the subthemes of working conditions, postgraduate career paths, labor market conditions, and safety/exposure to violence (online supplementary data Table B). Participants consistently highlighted the intensity and unpredictability of the working load during residency. This contributed to cumulative fatigue, with some participants describing how even essential activities such as eating, resting, or praying were compromised by the demands of the role. The onset of the COVID-19 pandemic exacerbated these conditions, with participants reporting prolonged 24-hour shifts in full personal protective equipment as “catastrophic.” Although Arabic was the native language of participants, the transition from studying medicine in English to documenting patient data in Arabic was a significant challenge, as many were unfamiliar with Arabic medical terminology, which increased the cognitive load and contributed to the overall workload.

Labor market conditions, including increased retirements and migration, played a significant role in participants’ transition experiences, with several residents reporting that colleagues had left due to stress or lack of opportunity, resulting in increased workloads for those who remained. Safety and exposure to violence emerged as key factors, particularly verbal and physical aggression.

Support

This theme explores the various forms of support experienced by participants during the TTR, including the subthemes of interpersonal (peers, senior colleagues, and family), interprofessional, and institutional support resources—or the lack thereof (online supplementary data Table C). Peer support was perceived as the “most valuable” form of interpersonal support because it provided emotional reassurance, a sense of shared understanding, and practical assistance in managing daily challenges. In contrast, the support received from senior colleagues was heterogenous: while some participants described highly supportive supervisors and consultants, others reported limited access to experienced mentors. Instead, they were supervised by near-peers who lacked the authority and expertise to provide adequate support, leading to feelings of uncertainty and mistrust. Support from interprofessional teams, particularly nursing staff, was valuable, as it offered affirmation, practical assistance, and encouragement during clinical tasks. Participants who initially faced strong opposition to their career choice reported lacking family support, which limited their ability to express vulnerability or seek emotional support outside of work. The level of institutional support was variable, with some receiving structured orientation weeks and shadowing programs, while others were expected to assume clinical duties immediately without any formal introduction or guidance. Institutional support for workload and well-being was sometimes perceived as rigid and lacking, with some participants reported as having been required to work while ill or to arrange their own replacements.

Strategies

This theme explores the coping mechanisms, behaviors and resources used by participants to navigate the transition to residency, and subthemes include individual, institutional, and interprofessional collaboration strategies (online supplementary data Table D). The analysis revealed a spectrum of individual strategies ranging from constructive strategies to less effective avoidant behaviors. At the adaptive end of the spectrum, some participants intentionally maintained their psychological well-being through self-care routines and hobbies. In contrast, others reported having no specific coping strategies, attributing this to overwhelming clinical demands and a lack of time for reflection or rest. Individual strategies also included psychological adaptation, with several participants describing an increased emotional resilience and assertiveness. However, some expressed ambivalence about the personal cost of this change, such as the loss of emotional sensitivity. Self-directed learning (SDL) emerged as a prominent coping strategy, particularly in contexts where formal teaching was not provided. In contrast, some participants viewed SDL as a burden, indicating inadequate institutional support and educational gaps, to the extent that they considered leaving the residency program altogether. Similarly, other maladaptive individual strategies included various forms of avoidance, such as rejecting feedback from peers or juniors based on rigid hierarchical views of competence and authority. At the more extreme end of avoidant strategies, several participants were preparing for external examinations and applying for jobs abroad as a means of escaping the current system.

Institutional strategies played an important role, and structured training and the gradual entrustment of clinical responsibilities were viewed as particularly effective in fostering confidence and competence. Importantly, participants noted that senior residents acted as safety nets by intervening when they recognized that a junior resident was overwhelmed or “drowning.” Participants valued the role of interprofessional collaboration in helping them to navigate difficult situations, particularly when carrying out stressful or unfamiliar tasks.

Discussion

The TTR is a pivotal stage in a physician’s professional development, yet little is known about how residents in resource-limited, non-Western settings experience and navigate this critical phase. Our findings reveal that residents’ adaptation to their new roles was shaped by 4 interconnected domains: individual preparedness, identity, and gendered experiences (self); demanding working conditions, postgraduate training requirements, and safety concerns (situation); the heterogeneity of interpersonal, interprofessional, and institutional support systems (support); and the wide spectrum of coping mechanisms, ranging from resilience-building and SDL to avoidance and withdrawal (strategies).

Regarding “self,” our findings show that the abrupt shift from protected undergraduate training to the autonomy and accountability of residency evokes fear and self-doubt, consistent with prior research showing new residents often feel unprepared for independent practice, particularly in complex procedures and nontechnical skills.^36,37 Central to this shift is the expansion of roles and responsibilities, with residents moving from observing and assisting to being the primary physician—findings that align closely with prior literature describing the profound role changes that occur during this transition.³⁸ Consistent with studies from high-income countries, we found that gender shaped residents’ transition experiences, with women participants describing resistance from patients and colleagues and discomfort in male-dominated environments.^39,40 However, unlike studies that portray exclusion as being imposed by team members, our findings suggest that women sometimes deliberately distance themselves from colleagues who are men, reflecting a more complex interplay of gender, religion, and cultural expectations within Middle Eastern health care settings.⁴¹

In terms of “situation,” our findings revealed that residents faced demanding and unpredictable workloads, which aligns with previous research that identified workload and fatigue as key stressors during the transition to residency, regardless of whether the setting was high-income or low-resource.^42,43 Workforce shortages due to migration and attrition further compounded these pressures, leaving smaller teams with greater responsibilities, a dynamic less visible in contexts with more stable staffing.⁴⁴ A distinctive feature in our context was the transition from English-based medical undergraduate study to Arabic documentation in the workplace. This linguistic shift has added a cognitive load that affects processing efficiency and accuracy in Arabic diglossic settings, where navigating between different registers of Arabic complicates written expression and professional communication.^45,46 Notably, the “self” and “situation” themes are interconnected, with residents’ experiences of fear and self-doubt shaped by gendered expectations in daily interactions and further compounded by the cognitive load introduced by the language shift. These intersecting cultural, gendered, and linguistic factors demonstrate that individual adaptation occurs within—and is constrained by—the broader contextual demands of practice.

Regarding “support,” residents’ experiences were anchored in dense, informal peer networks that acted as the most reliable and accessible safety net, which is consistent with previous studies where peer support played a vital role in easing the transition by offering emotional reassurance, a shared understanding, and practical assistance.^47,48 However, unlike in high-income settings where peer support is often formalized through mentorship, near-peer initiatives, or structured groups, there were no formal programs in our setting. Instead, informal and personal efforts filled the gaps left by limited institutional support.

In terms of “strategies,” a wide spectrum of coping responses ranging from adaptive to avoidant was observed. These reports echo—and amplify—those from high-income settings, where workload is a barrier to wellness.⁴⁹ SDL was a prominent strategy involving surgical videos, extensive reading, and just-in-time materials. Unlike in the literature, where SDL is framed as a crucial skill fostered through individualized plans, coaching, and structured goal-setting,⁵⁰ SDL occurred without supervision, scaffolding, or program alignment in our context.

Limitations and Future Research

This study has some limitations. Reliance on translated transcripts restricted the ability to conduct a detailed discourse analysis, a step that would have added depth to the analysis of emotions and perceptions. Although purposive maximum-variation sampling was used to ensure diversity across key dimensions, the subsequent use of snowball sampling to reach additional participants may have introduced the possibility of network-based recruitment bias.²⁹ Additionally, the sample was limited to residents in university-based programs and did not include those training in the Egyptian Board system, which may differ in structure and context. Future research should expand the scope to include both university- and board-based residency programs to capture a more comprehensive national perspective. Furthermore, evaluating the feasibility and impact of targeted interventions, such as structured orientation in documentation languages, formal peer mentoring, and progressive entrustment frameworks, across different training models will help identify sustainable strategies to improve residency transitions in contexts with limited resources.

Conclusions

Our study of surgery and EM residents’ transition experiences reveals how structural challenges and workforce pressures shape early adaptation in contexts with limited resources.

Author Notes

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

Editor’s Note

The online version of this article contains the discussion guide used in the study and quotes from participants.