Adapting to clinical responsibility: Challenges and learning environment in early practice—a longitudinal study

The transition from medical student to doctor is widely recognized as a challenging period, yet most studies capture this transition at single time points and provide limited guidance on how educational environments can better support learners. Longitudinal insights are needed to understand how challenges emerge, how learners adapt, and where educational interventions may be most effective. This study aims to explore how medical students experience and adapt to increasing clinical responsibility across the transition from clerkship to the first postgraduate year (PGY1), interpreted through Gruppen’s Learning Environment Framework. This longitudinal study was conducted between August 2017 and July 2020 using audio diaries collected from medical students as they progressed from clerkship through their first postgraduate year (PGY1). Participants recorded regular audio diaries reflecting on experiences that made them feel unprepared for clinical practice. Data were analyzed inductively to identify recurring challenges and coping strategies. Gruppen’s learning environment framework was subsequently used as an analytic scaffold to organize findings across personal, social, and organizational domains and to inform intervention-oriented interpretation. During clerkship, learners reported substantial challenges related to applying theoretical knowledge to patient care, limited participation within clinical teams, and uncertainty about professional roles and responsibilities. As learners transitioned into PGY1, they described adaptive processes including proactive engagement in clinical tasks, relationship-building with supervisors and team members, and increased self-reflection. Longitudinal analysis demonstrated both continuity and change across the transition: while some challenges persisted, learners’ responses evolved as they assumed greater responsibility and autonomy. This study illustrates how challenges during the transition to practice are shaped by learning environment factors and how learners adapt over time. Using a learning environment framework as an analytic and intervention-guiding tool, the findings offer practical insights for designing educational strategies to better support learners as they move from student to doctor.