|Year : 2014 | Volume
| Issue : 3 | Page : 114-122
Factors affecting Family Medicine residents' perception of achievement of training objectives
Ammar Radi Abu Zuhairah, Kasim Mohammad Al-Dawood, Amar Hassan Khamis
Department of Family and Community Medicine, University of Dammam, Dammam, Saudi Arabia
|Date of Web Publication||31-Jul-2014|
Ammar Radi Abu Zuhairah
Qatif, Abu Bashir Al-Zubaidi Street, PO Box 1518, Qatif 31911
Aims: To measure the association between number of patient encounters and training provided to residents, as well as the residents' perceived achievement of training objectives.
Settings and Design: This cross-sectional study was done on Family Medicine residents in Eastern province, Makkah and Asir regions.
Materials and Methods: A questionnaire was developed by the investigator and validated by two experts. All residents, except first year residents, were included. Data were collected by the investigator through direct contact with the residents.
Statistical analysis: Cronbach's alpha, analysis of variance, t-test, and univariate regression model were used.
Results: Reliability of the questionnaire was found to be 75.4%. One hundred and seven residents (response rate, 83.6%) had completed the questionnaire. The mean age was 29.1 ± 2.5 years, half of the residents were male, most of them (83.2%) were married, and more than half (54.2%) of the residents had worked in primary health care (PHC) before joining the programme. Age and duration of work in PHC before joining the programme were significantly and positively associated with the outcome. In Family Medicine rotations, continuity of care, percentage of patients discussed, and number of trainers were associated with the outcome. On the other hand, percentage of patients discussed in different settings and opportunity for the residents to evaluate patients in an outpatient setting were among the factors affecting the outcome in the hospital rotations.
Conclusions: Factors identified (age, duration of work in PHC, discussion, and opportunity to evaluate patients) might help residents, trainers, and decision makers in ensuring residents benefit from the different rotations. Further studies to link the effect of the identified factors on resident outcome and patient care are required.
Keywords: Clinical training, Family Medicine, postgraduate training
|How to cite this article:|
Abu Zuhairah AR, Al-Dawood KM, Khamis AH. Factors affecting Family Medicine residents' perception of achievement of training objectives. J Health Spec 2014;2:114-22
|How to cite this URL:|
Abu Zuhairah AR, Al-Dawood KM, Khamis AH. Factors affecting Family Medicine residents' perception of achievement of training objectives. J Health Spec [serial online] 2014 [cited 2020 Oct 1];2:114-22. Available from: http://www.thejhs.org/text.asp?2014/2/3/114/137887
| Introduction|| |
Postgraduate training changes continuously. Recently, training has been focused on outcome-based education.  The background of this approach comes from the adult learning theory. One of its concepts is that residents gain experience from patient consultations (experiential learning). 
The specialty of Family Medicine is a demanding one; it requires a wide range of experience and knowledge.  Residents should be exposed to common health problems seen in the ambulatory care setting. , However, training of residents varies among different training centres. This could be because of the variability in number of patients encountered and their diagnoses, age and sex, communities they serve, and other factors. In order to meet the demands of the community, it is necessary to constantly evaluate residents' training. ,,,
Saudi Arabia is in great need of Family Physicians. During the four years in the Family Medicine residency programme, residents are exposed to 13 specialties. Family Medicine residents spend most of the programme period rotating in different hospitals/training centres. 
To the best of our knowledge, only a few studies have addressed residents' training in Saudi Arabia. ,,, The aim of the study was to evaluate factors affecting clinical Family Medicine training in Saudi Arabia. Specifically, the objective was to measure the association between the number of patient encounters and the training given to residents, and the residents' perceived achievement of the training objectives (PATO) as per regulations of Saudi Commission for Health Specialties (SCFHS). 
| Materials and Methods|| |
Eastern province, Makkah and Asir regions were selected to conduct the study. The Eastern province was the primary area because the investigator was located and trained in this area during the study period. Makkah and Asir were included to increase the sample size.
A nine page questionnaire was developed by the investigator and validated by two experts [Appendix I [Additional file 1] at the end of this article]. A pilot study was then prepared on five recently graduated Family Medicine specialists. The questionnaire was composed of seven parts: Demographic data, Family Medicine rotation, inpatient work, duty work, Emergency Department (shift) work, outpatient work and PATO (the outcome). A five point Likert scale was used to measure the outcomes. All the questions were closed-ended with 3 - 5 options (to reduce time and effort in answering the questionnaire). Names or any identifying data were not collected to guarantee correct responses.
The target population of the study was all programme residents at the time of the study Eastern province, Makkah and Asir regions. Residents in the first year of the programme were excluded since they had only finished one rotation. Furthermore, residents who had started the programme in an area other than the study areas were excluded since the training they had did not reflect the training in the selected regions and province.
Data was collected by the investigator through direct contact with the residents. Instructions were provided, together with any clarifications required. Most of the non-respondents in the Eastern province were contacted through direct contact, phone calls and/or e-mails. All participants were invited to participate in the study based on their own free-will. As participants were anonymous, no informed consent was requested. Furthermore, all data collected were used only for research purpose.
Statistical analysis was performed using SPSS 16.0. Reliability of the questionnaire was tested by Cronbach's alpha. A total score was calculated for each resident by summation of his/her PATO. A normality test (Kolmogorov-Smirnov) was performed for the score of PATO. Analysis of variance (ANOVA) and t-test were used to test significance between continuous variables. In this study, a P-value of less than 0.05 was considered significant in all the tests.
A univariate regression model was used to explain PATO by explanatory variables. Variables with significant association on ANOVA testing were included in the analysis, namely age-group and work experience in PHC. The PATO was coded from 1 (strongly disagree) to 5 (strongly agree). Age was categorized into three age-groups, ≤ 28, 29 - 32 and ≥ 33. Work experience in PHC was categorized to those who worked for < 6 months, 6 - 24 months, and those who had worked for > 24 months.
| Results|| |
Reliability of the questionnaire was found to be 75.4%. A total of 107 residents (response rate, 83.6%) completed the questionnaire. Out of 21 non-respondents, 13 (61.9%) were male, and the majority (66.7%) were in the Eastern province.
The mean age of participating residents was 29.1 ± 2.5 years, with similar number of male and female residents. The majority (83.2%) of residents were married. More than half (54.2%) had worked in a PHC before joining the programme [Table 1]. Residents who were categorized under the age-group 29 - 32 years and those who had worked for 6 - 24 months had better PATO (P < 0.007 and P < 0.012, respectively).
Regression analysis performed for the demographic characteristics appeared to be significantly associated with the PATO [Table 2], that included age-group and work experience in PHC. The fitness of the model was significant (P < 0.007). The result of the regression analysis revealed that 11.6% of the PATO was explained by the variables in the model. The significant association shown previously with the age was not observed in the univariate analysis. On the other hand, the significant association of work experience in PHC was observed. However, this significant correlation was decreased and became not significant when age as an additional variable was combined with it.
Of the variables tested in Family Medicine rotations, continuity of care, percentage of patients discussed and number of trainers were all found to affect the PATO [Table 3]. However, the number of trainers was significantly associated with PATO only in Family Medicine 1 rotation. There is insufficient evidence to suggest a significant association between the number of clinics assigned to residents per week or the number of cases encountered per clinic with the PATO.
|Table 3: Association between variables in Family Medicine rotations and residents' PATO |
Click here to view
With regards to working at the inpatient setting, the only significant factor found to be associated with residents' PATO was the discussion of patients during rounds. This was the case in the Internal Medicine (P < 0.016), Paediatric (P < 0.029), and Obstetrics and Gynaecology (P < 0.003) rotations. However, the effect of discussion was not found to be significant in the General Surgery (P < 0.142) and Psychiatry (P < 0.731) rotations. There were no significant associations between the number of patients assigned to the residents, the number of rounds the trainer attends or the duration of the round and PATO in all rotations.
Two factors were found to be associated with PATO from scheduled working duties. The most consistent factor was the discussion of patients encountered during duty hours (P < 0.005, 0.050 and 0.006 for Internal Medicine, Paediatric and General Surgery, respectively). Being the first on-call was associated with better PATO in Internal Medicine (P < 0.018) and General Surgery (P < 0.024). However, this association was not found in Paediatric rotation (P < 0.469). It was found that there were no significant associations between the number of duties or the number of admissions and PATO in any rotation.
The presence of a trainer during the shift was found to be associated with better PATO in the Emergency Department setting of the Paediatric (P < 0.011) and Obstetrics and Gynaecology (P < 0.024) rotations, but not in the Emergency Medicine rotation. However, there was no evidence to suggest any significant association between number of shifts or number of patients encountered and PATO. In addition, no significant association was found between percentage of patients discussed and PATO, as shown in other settings (inpatient, duties and outpatient).
In the outpatient setting, two factors were associated with PATO. The most consistent factor was the percentage of patients evaluated by the residents. This association was found in all the rotations except in Paediatrics (Internal Medicine: P < 0.001; Paediatric: P < 0.067; Obstetrics and Gynaecology: P < 0.032; General Surgery: P < 0.038; Psychiatry: P < 0.024; Orthopaedic: P < 0.002; Otolaryngology: P < 0.015; Dermatology: P < 0.022; Ophthalmology: P < 0.003). Furthermore, the percentage of patients discussed was associated with a better PATO in Internal Medicine (P < 0.003), Obstetrics and Gynaecology (P < 0.027), General Surgery (P < 0.002) and Orthopaedics (P < 0.001). There was no significant association between the percentage of clinics covered by a trainer or the number of patients encountered in the outpatient setting, and PATO.
| Discussion|| |
The overall response rate was good, given the short duration of the study period, and the great distance of Makkah and Asir regions from the Eastern province. This response rate is likely to be representative of the residents in the programme and areas studied, and it was higher than other studies. ,,
The mean age of the participants was slightly less than the mean age in other national studies.  This was because about half of the residents joined the programme immediately following graduation from medical college. Almost half of the residents were female. This is higher than previous studies in Saudi Arabia. , This could provide a positive impact, since half of the Saudi population is female,  and Muslim women prefer to be evaluated by female doctors. A majority of residents were married (83%), which was similar to other national studies. , It was found from this study that those residents who worked in PHC before joining the programme had a better PATO. Other studies also support this finding. , Residents who worked in PHC before starting hospital rotations were more likely to receive training relevant to their practice. This could be because they were able to direct their training towards their needs, or they appreciated what was actually relevant. 
In the Family Medicine rotation, residents had a better PATO if there was continuity of care. This was found in several studies. ,, In addition, they had a better PATO if they had adequate discussion, which agrees with other studies. ,, Discussion of at least 25% of the patients encountered was found to be adequate in most rotations and settings. This also supports earlier findings that trainers should take the opportunities offered by patient encounters for teaching in the ambulatory setting.  Furthermore, this study emphasizes the importance for the role of the clinical trainer in Family Medicine.
In hospital rotations, the most consistent factor found to be associated with the level of PATO was the discussion of patients encountered in different settings (except in the emergency setting). This was the finding of several other studies. ,,, Adequate opportunity to evaluate patients in the OPD settings had similar importance. In most rotations, evaluation of at least 25% of patients was found to be adequate. The conclusions of two studies were similar to our findings. , However, it was the opposite to those of van der Zwet et al.  In duty settings, this study concentrates on the importance of working as the first on-call, as concluded in two other studies. , In an Emergency Department setting, the presence of a trainer during the shift was associated with better PATO in Paediatric, and Obstetrics and Gynaecology rotations.
There was minimal on effect on the number of patients encountered in different hospital settings. This finding contradicts what has been shown that self-perceived learning is related to the number of cases encountered.  A possible explanation might be that most of the residents had adequate patient exposure.  In addition, the presence of a trainer had a minimal effect. On the other hand, trainer availability was one of the most important factors as suggested by Stewart J and Hyde P.  It seems that the work load in different settings had no effect on the PATO. It might be that the quality of training rather than the quantity is the factor that affects achievement.
This study was conducted in Eastern province, Makkah and Asir regions of Saudi Arabia. Therefore, generalisation of the results to other provinces, regions or other countries might not be appropriate. Some rotations were finished 1 or 2 years before data collection. Therefore, recall bias cannot be excluded. The outcome was the residents' PATO; its effect on the residents' competence and exam performance is unknown. Difficulties faced were in the form of limited time and resources (self-funding).
| References|| |
|1.||Harden RM. Trends and the future of postgraduate medical education. Emerg Med J 2006;23:798-802. |
|2.||Royal Australian College of General Practitioners. The RACGP Curriculum for Australian General Practice 2011. |
|3.||Tiemstra JD. Fixing family medicine residency training. Fam Med 2004;36:666-8. |
|4.||Morgan S, Magin PJ, Henderson KM, Goode SM, Scott J, Bowe SJ, et al. Study protocol: The registrar clinical encounters in training (ReCEnT) study. BMC Fam Pract 2012;13:50. |
|5.||Damen A, Remmen R, Wens J, Paulus D. Evidence based post graduate training. A systematic review of reviews based on the WFME quality framework. BMC Med Educ 2011;11:80. |
|6.||Moran-Barrios J, Ruiz de Gauna Bahillo P; Miembros de la Junta Directiva de la Sociedad de Educación Médica de Euskadi. Reinventing specialty training of physicians? Principles and challenges. Nefrologia 2010;30:604-12. |
|7.||Lockyer J, McDougall GM, McLeod LE. Residency training in family practice: How many residents, faculty and rotations. Can Fam Physician 1982;28:1648-51. |
|8.||Stewart GT, McAvoy P. Residents evaluate their training in family practice. Can Fam Physician 1978;23:487-91. |
|9.||Saudi Commission for Health Specialties. Saudi Board of Family Medicine Curriculum 2011. |
|10.||Al-Khathami AD. Evaluation of Saudi family medicine training program: The application of CIPP evaluation format. Med Teach 2012;34 Suppl 1:S81-9. |
|11.||Al-Omran AM, Al-Haqawi AI. Resident's perception of the characteristics of effective clinical trainer. [Dissertation] Riyadh: King Fahad National Guard Hospital; 2001. |
|12.||Al-Rowais N, Al-Ghamdi E. Views of primary health care trainees on their hospital training in internal medicine and pediatrics in Saudi Arabia. J Family Community Med 2000;7:43-51. |
|13.||Al-Sebiany AM. Perceived competencies in family medicine residency programs in Saudi Arabia. [Dissertation] Dammam: King Faisal University; 1999. |
|14.||Reeve H, Bowman A. Hospital training for general practice: Views of trainees in the North Western region. BMJ 1989;298:1432-4. |
|15.||Central Department of Statistics and Information. General census on population and housing. Available from: http://www.cdsi.gov.sa/index.php?option=com_content&view=article&id=88 [Last accessed on 2013 May 21]. |
|16.||Little P. What do Wessex general practitioners think about the structure of hospital vocational training? BMJ 1994;308:1337-9. |
|17.||Crawley HS, Levin JB. Training for general practice: A national survey. BMJ 1990;300:911-5. |
|18.||Schers H, van de Ven C, van den Hoogen H, Grol R, van den Bosch W. Family medicine trainee still value continuity of care. Fam Med 2004;36:51-4. |
|19.||Schultz KW, Kirby J, Delva D, Godwin M, Verma S, Birtwhistle R, et al. Medical students' and residents' preferred site characteristics and preceptor behaviors for learning in the ambulatory setting: A cross-sectional survey. BMC Med Educ 2004;4:12. |
|20.||Roth LM, Severson RK, Probst JC, Monsur JC, Markova T, Kushner SA, et al. Exploring physician and staff perceptions of the learning environment in ambulatory residency clinics. Fam Med 2006;38:177-84. |
|21.||Bowen JL, Irby DM. Assessing quality and costs of education in the ambulatory care setting: A review of the literature. Acad Med 2002;77:621-80. |
|22.||Stewart J, Hyde P. Learning from the learners: What do trainees want from general practice vocational education? Asia Pac Fam Med 2002;1:28-32. |
|23.||Wearne SM. Pilot study on factors that influence learning by general practice registrars in central Australia. Rural Remote Health 2003;3:223. |
|24.||Bowen JL, Stearn JA, Dohner C, Blackman J, Simpson D. Defining and evaluating quality for ambulatory care educational programs. Acad Med 1997;72:506-10. |
|25.||Cyna AM, Przyslo FR. Are the recommendations being met in the general practice year of vocational training? Trainees' views in the West Midlands region. Br Med J (Clin Res Ed) 1987;294:416-8. |
|26.||van der Zwet J, Hanssen VG, Zwietering PJ, Muijtjens AM, Van der Vleuten CP, Metsemakers JF, et al. Workplace learning in general practice: Supervision, patient mix and independence emerge from the black box once again. Med Teach 2010;32:e294-9. |
|27.||Haney EM, Nicolaides C, Hunter A, Chan BK, Cooney TG, Bowen JL. Relationship between resident workload and self-perceived learning on inpatient medicine wards: A longitudinal study. BMC Med Educ 2006;6:35. |
[Table 1], [Table 2], [Table 3]