Postgraduate Medical Training; Resident quality of education

72 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (1): 72-76
INTRODUCTION
Postgraduate medical education entails a diverse
continuum of learning in the context of providing medical
care to patients. The learning and educational process
during residency is highly dynamic and involves a
complex interplay among a variety of factors. For
instance, the workload and working environment, formal
educational activities, and careful supervision and
feedback by faculty etc. all have a bearing on learning
during residency.1,2 The existing standards of residency
training have evolved as a result of long standing
educational research and evidence base, side by side
with technological advancements in medicine.3-5 In the
United States, the Accreditation Council for Graduate
Medical Education (ACGME) identified six learning
outcomes for postgraduate medical education. These
include patient care, medical knowledge, interpersonal
communication skills, professionalism, practice based
learning, and system based practice.6-8
The issues surrounding postgraduate medical education
have been debated for long in the developed countries,
however, there has been little contribution to these
intellectual debates from developing countries.3,5,9,10
Surveys that entail residents' ratings of their residency
have been under continuous scrutiny and they are
increasingly employed to identify and rectify deficiencies
in residency training.
The present study was conducted to measure the level
of satisfaction among residents with regards to various
educational attributes of their training and hence evolve
actionable evidence base to effect meaningful changes
for improved quality of training.
METHODOLOGY
This cross-sectional study was conducted at the
Department of Medical Education, (DME), Pakistan
Institute of Medical Sciences (PIMS), Islamabad over a
period of 3 months, from September to November 2008.
The study included residents who had been pursuing
residency training in different specialties for over a
period of one year. The target was to get the question-
naires responded from a heterogeneous group of
residents encompassing all specialties and residency
SURVEY REPORT
Postgraduate Medical Education:
Residents Rating the Quality of Their Training
Muhammad Saaiq and Khaleeq-uz-Zaman
ABSTRACT
Objective: To determine the residents' rating of the quality of their residency training by measuring their level of
satisfaction with the various educational attributes of their training.
Study Design: Cross-sectional survey.
Place and Duration of Study: Department of Medical Education (DME), Pakistan Institute of Medical Sciences (PIMS),
Islamabad, from September to November 2008.
Methodology: Residents who had been pursuing residency training for over a period of one year were included. A
comprehensive questionnaire consisting of 14 questions was employed which covered fundamental attributes of the
quality of postgraduate training. A five point response scale was used to rate responses to questions. Results for each of
the measures of all the included residents were added up, and then an average was calculated and scaled to a score out
of 100 to form the Index Score. In this way the residents' level of agreement or disagreement with the questioned statement
was measured from 'Strongly disagree' (0%) to 'Strongly agree' (100%).
Results: Out of a total of 150 residents contacted, 109 answered the questionnaire. The response rate was thus 73%.
Residents variably rated the various educational attributes of their residency training. Relatively favourably rated areas
included regular conduct of case/ topic discussions (75.96%), consultant's supervision during interventional procedures
(70.27%) and regularly holding journal clubs (69.54%). The less favourably rated areas included constructive feedback by
supervisor (54.49%), consultant as role model (54.49%) and faculty as the source of learning (50.82%). Overall, the Index
Score was 60.55%.
Conclusion: Significant room exists for improvement in the quality of residency training as indicated by the less than
desirable ratings of the various educational attributes of the residency programme. Faculty members who constitute the
cornerstone of educational process are pivotal to effect the desired improvements.
Key words: Postgraduate medical education. Residency training. Quality of training.
Department of Medical Education, PIMS, Islamabad.
Correspondence: Dr. Muhammad Saaiq, Room No. 20, MOs
Hostel, PIMS, Islamabad.
E-mail: muhammadsaaiq5@gmail.com
Received May 20, 2011; accepted December 23, 2011.

programmes. They were randomly approached face-to-
face. Residents who were unwilling to participate were
excluded. The study was conducted in accordance with
the Declaration of Helsinki of 1975, as revised in 1983
and anonymity of the participants was guaranteed.
A comprehensive questionnaire was employed which
covered the fundamental attributes of the quality of
postgraduate training. It was constructed to meet our
survey objectives. The questionnaire was pre-tested on
a group of 15 residents. The questions were phrased in
such a way that an agreement/satisfaction with the
accepted standards got higher score, while disagreement/
dissatisfaction scored low.
The key questions/attributes included affirmation of
undergoing a structured residency programme, cases/
topic presentations being regularly held in the ward,
weekly teaching round being regularly held in addition to
daily business round, Journal club being regularly
held, multidisciplinary meetings/grand rounds being
regularly held, using internet for searching medical
literature, source of learning, consultant accessibility in
OPD, senior/consultant availability for supervision during
surgery or procedures, professor / consultant providing
regular constructive feedback on progress, quality of
supervision and consultant being a good role model.
At the conclusion of the questionnaire the residents were
asked for any additional suggestion for further improve-
ment.
The data were analysed through Statistical Package for
Social Sciences (SPSS) for Windows version 10 and
various descriptive statistics were employed to calculate
frequencies, means and standard deviation. The
categorical data such as gender distribution, residency
programme were reported as frequency and percent-
ages. The numerical data such as age were reported as
mean ± S.D. The responses to the questions were rated
on a 5 point response scale. If the response was
'strongly agree' it scored 5 points, 'Agree' 4, 'Neither
agree nor disagree' 3, 'Disagree' 2 and 'Strongly
disagree' 1 point. No response was awarded zero point.
Results for each of the measures of all the included
residents were added up, and then an average was
calculated and scaled to a score out of 100 to form the
index score. In this way the residents' level of agreement
or disagreement with the questioned statement was
measured from Strongly disagree (0%) to Strongly agree
(100%).
RESULTS
In the target population of 150, residents were contacted
and 109 returned the questionnaires duly answered,
constituting a response rate of 73%. Out of 109 respon-
dents, 74 were males (68%) while 35 were females (32%).
Majority of respondents (67%) were pursuing FCPS
while 36 were undergoing other degree programmes
(27%) including MS, MD, MCPS and M.Phil. The age was
25 – 41 years with a mean value of 31.60 ± 4 years.
Residents variably rated the various structural attributes
of their residency training as asked in the questionnaire.
Relatively favourably rated areas included regular
conduct of case/topic discussions (75.96%), consultant's
supervision during interventional procedures (70.27%),
regular holding of journal clubs (69.54%), holding of
multidisciplinary meetings (68.80%), regular weekly
teaching round (68.49%), use of Web based search for
medical literature (68.07%), learning from self/other
colleagues (65.50%), and consultant supervision in
general (57.06%). The least favourably rated areas
included regular constructive feedback by supervisor
(54.49%), consultant as role model (54.49%), faculty as
a source of learning (50.82%), residency as structured
programme (50.64%), regular meeting with consultant to
discuss progress (47.52%), and accessibility of consul-
tants in OPD for case discussion (46.05%). Table I
shows the responses of residents to the different
questions.
Overall, the Index score was 60.55 %. It was calculated
by initially adding-up the response scores (i.e. Strongly
agree = 5, Agree = 4, Neither agree nor disagree = 3,
Disagree = 2 and Strongly disagree = 1) of all the
included attributes (of all the included residents), then
measuring an average which was scaled to a score out
of 100.
DISCUSSION
Majority of residents agreed with the fact that case/ topic
discussion, teaching rounds, multidisciplinary meetings,
and grand rounds were held regularly.
Residents awarded relatively high rating (69.54%) to
the journal club. The journal club is a useful academic
activity that entails formal regular meeting of the ward
doctors to critically appraise articles published in current
medical journals, Our findings are in conformity to those
of Crank-Patton et al. who surveyed the program
directors of general surgery and found that 65% of them
organized a regular journal club.11 Akhund et al. in a
Karachi-based study found journal club a useful learning
modality and have recommended effective use of online
resources to support journal clubs as a successful
alternative to excessive expenditure for obtaining print
journals.12 In fact evidence-based medicine is one
common interpretation of the ACGME mandate for
practice-based competency and journal club is an
effective tool to achieve that competency.13 The teaching
process of the journal club should be interactive and
should be based on adult learning principles. The format
should emphasize a limited number of original articles
reviewed in depth, inclusion of basic epidemiology and
statistics, a structured review checklist, and defined
objectives for the participants.13 The journal club should
Residents rating the quality of their training
Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (1): 72-76 73

inculcate critical appraisal skills among the doctors and
promote evidence based approach among them.
Attendance by faculty as well as trainees should be
made mandatory in order to make this tool more
effective teaching activity.
Residents reported most of their learning to be from
Web based search (68.07%) or self-learning/learning
from other fellow colleagues (65.5.%). Faculty as the
source of learning was given low scores (50.82%).
Internationally there is growing recognition of the
importance of the contribution of Web based resources
to postgraduate medical education.14,15 However,
faculty's contribution to residents' training is also crucial
as residents tend to have positive feelings for those
teachers who not only focus on routine patient care
but also give due attention to the education of their
Table I: Residents' ratings of the quality of training (n=109).
Questions and responses Number (%)
1. I am undergoing a structured residency programme.
Strongly disagree 17 (15.59%)
Disagree 41 (37.61%)
Neither agree nor disagree 29 (26.60%)
Agree 20 (18.34%)
Strongly agree 02 (1.83%)
Not answered -
2. Cases/ topic presentations are regularly held in our ward.
Agree 44 (40.36%)
Not answered -
3. Weekly teaching round is regularly held in addition to daily business round.
Agree 45 (41.28%)
Not answered -
4. Journal club is regularly held in our ward.
Agree 31 (28.44%)
Not answered -
5. Multidisciplinary meetings / grand rounds are regularly held in our ward.
Agree 31 (28.44%)
Not answered -
6. I regularly use internet for searching medical literature.
Agree 40 (36.69%)
Not answered -
7. Most of my learning is from the faculty members.
Agree 22 (20.18%)
Not answered 07 (6.42%)
8. Most of my learning is from myself or other resident colleagues.
Agree 51 (46.78%)
9. My consultant is accessible in OPD for discussing patients.
Disagree 04 (3.66%)
Agree 47 (43.11%)
10. My senior/consultant is available for supervision during surgery or procedures.
Disagree 07 (6.42%)
Agree 35 (32.11%)
Strongly dgree 25 (22.93%)
11. My professor / consultant gives me regular constructive feedback.
Agree 19 (17.43%)
12. I regularly sit with my consultant/ professor to discuss my progress.
Agree 10 (9.17%)
13. My consultant's supervision is excellent.
Agree 23 (21.10%)
14. My consultant is a good role model for me.
Neither Agree nor disagree 21 (19.26%)
Agree 28 (25.68%)

trainees.16 E-learning offers certain added advantages.
For instance a wealth of online medical literature is
available on all specialties and can be accessed any
time by the trainees. E-learning has the potential to
transform postgraduate medical education in future.
Residents reported poor appraisal and feedback from
consultant. The low scores (54.49%) given to faculty by
residents in this area indicates an important area of
deficiency in training. A Karachi-based study also
reported similar findings.17 Biggs an Australian edu-
cationist who recently conducted a survey of Pakistani
doctors also found lack of proper appraisal and
mentoring for trainees regarding their training.18 In fact it
is needed to evolve a culture of educational agreements
between the trainee, trainer and postgraduate dean /
hospital. This will promote a healthy environment of
open communication, appraisal and feedback among
them.3,18
Supervisor as a role model was relatively low rated area
(54.49%). It is now well recognised that individuals with
specific responsibilities for education and training must
have opportunities to develop additional specialised
skills to serve as role models for their mentees. A wide
range of face-to-face and distance learning courses are
now available to meet these essential requirements.
They should be able to go beyond the improvement of
specific teaching skills, adopt diverse educational
formats, use staff development programmes and
activities to promote organisational change.19-21
Six surgical residents variably expressed concerns
about the growing interest of senior faculty in laparo-
scopic interventions. The situation is being perceived by
them as detrimental for training, causing lesser surgical
volume and fewer opportunities for meaningful
participation in surgery on elective lists. The growing
interest of the senior faculty in laparoscopic surgery
should not jeopardize the learning experience of more
novice learners, most notably junior residents. In the
face of the rapid emergence of such new technologies,
there is a dire need to review and redesign the entire
spectrum of surgical residency programmes. This will
ensure meaningful participation of the trainees in the
various surgical procedures, building their capacity to
become safe surgeons. Also the issues concerning the
non-availability of laparoscopic instruments in periphery
where most of the residents go for service after
completing residency, need to be addressed. In this
context the residents feel unprepared for independent
performance of open surgical procedures also. Newer
teaching technologies such as the virtual reality-
simulation for the operating room22 can be employed to
address the aforementioned genuine concerns of the
residents.
Surveys and analyses of residents' ratings of various
attributes of residency training help to identify unrecog-
nized areas of deficiency in the training system. Hence,
such surveys should be conducted on regular basis and
translated into practice for improved outcomes. Further
research on essential attributes of residents' education
is needed to confirm and improve upon these results.
CONCLUSION
Significant room exists for improvement in the quality of
residency training as indicated by the less than desirable
ratings of the various educational attributes of the
residency programme. There is a need to revisit post-
graduate medical education and abolish the gap
between what is possible educationally and what is
being delivered at present. Faculty members who
constitute the cornerstone of educational process are
pivotal to effect the desired improvements.
Disclousre: This cross-sectional survey represents
second of the series of three surveys conducted
simultaneously by our institution's DME, which aimed to
establish baseline features of our residents education.
Conflict of interest statement: We declare to have no
conflict of interest. The authors do not have any financial
or personal relationships with other people or organi-
zation that could bias their work. There has been no
funding involved.
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