When I say … preparedness

Medical education researchers often want to predict the future, to know if teaching programmes or interventions will produce safe and competent doctors. Assessments tell us about students now, under examination conditions, but how they will perform in the future, in ‘messy’ workplaces, remains unknowable. The real-life performance of new doctors is hard to measure and is too confounded for links to specific educational experiences to be robust. Hence the concept of ‘preparedness’ has gained popularity in education research and policy. If students feel ‘prepared for practice’, we assume that intended educational outcomes have been achieved.1 Despite variable evidence of a relationship with performance,2 the value of the concept lies in its being, if not quite a crystal ball, then implicitly a proxy for future performance. However, on closer consideration the concept is less than clear. Operationalisation of the term, and its connotations, varies. So when we say ‘preparedness’, we must be clear what exactly we mean. Or rather, when we ask ‘Are you prepared…?’, we must consider what question research participants actually hear. This is the usual intent, and the question we hope will be answered. However, the future is unknowable and responses will involve some judgement of likelihood (‘How likely am I to be competent?’), judgement that is subject to well-documented cognitive biases.3 Being prepared may be understood as being competent in terms of the latest available evidence and so the question may be interpreted as asking: ‘Have you done well in your exams?’ Such judgements are at best redundant as assessment data already exist, but they are also vulnerable to cognitive biases in recall and interpretation. Rather than attempt to calculate likely performance, respondents may report a judgement of, or belief in, their own capability: ‘self-efficacy’.4 This is often associated with performance, but the relationship can be complex and mediated by factors such as task complexity.5 Feelings of preparedness may also reflect more general emotional states such as confidence or anxiety about entering a workplace. These may arise from (un)familiarity with the role, the physical workplace or its associated culture, staff and procedures. Anxiety may also arise from explicit concerns, such as about potential stress or bullying, or be linked to personality variables, such as neuroticism.6, 7 As well as ‘being prepared for’, preparedness may also mean ‘being prepared by’, with the object being the course, rather than the individual. Some studies do this explicitly by using items such as ‘My experience at medical school prepared me well…’7 rather than ‘Do you feel prepared…’8 In the former case the respondent must effectively parse two questions which ask not only ‘Do you feel prepared?’ but also ‘Is that attributable to the course?’ Such an approach also confounds the questions ‘What did you learn?’ and ‘What were you taught?’ Finally, whether the question is framed as prospective (‘Are you prepared?’8) or retrospective (‘Were you prepared?’7) is important. The retrospective question asks for a respondent's perception of his or her performance following transition, and so may provide a better estimate of actual performance than a prediction. However, the definition of ‘performance’ may itself vary subjectively. Additionally, such perceptions will still be open to biases, which may include cognitive biases that affect the recall of performance, but also contextual biases that arise from variability in new doctors' experiences. Doctors vary in the timing of the clinical exposure necessary to judge whether they were prepared, meaning that the influence of undergraduate training may be confounded by intervening experience in practice. Other retrospective views of preparedness may be gained from new doctors' colleagues,8 but these constitute an essentially different construct, referent to a group rather than to individual performance. Nonetheless they are vulnerable to similar sources of uncertainty. ‘Preparedness’ is therefore a problematic term, which does not map to a single unambiguous construct. This undermines its construct validity, and so its utility as a concept (whether it is operationalised quantitatively or qualitatively). Although the vernacular sense of describing doctors as ‘prepared’ or ‘unprepared’ remains useful, the rigour of academic discussion may be improved by specifying the precise construct we mean – performance, competence or confidence – when we say ‘preparedness’.