Respondents’ levels of training influenced their overall training satisfaction scores (Figure 1). Adjusting for facility and survey year, medical students’ satisfaction decreased from the first to the fourth year. (Δ = −0.67/year, 95% CI [−1.04, −0.30], t = 3.54, P < .001). In contrast, physician residents’ satisfaction scores were found to increase with level of training advances (Δ = 0.54/year, 95% CI [0.26, 0.83], t = 3.8, P < .001). In fact, PGY4 through PGY7 residents assigned higher overall training satisfaction scores to facilities than PGY1 through PGY3 residents (80.44 for PGY4 through PGY7 versus 78.92 for PGY1 through PGY3, Δ = 1.52, 95% CI [0.71, 2.34], t = 3.7, P < .001).
Association of domain satisfaction score with overall training satisfaction score
For medical students and residents, each domain’s score had a statistically significant association with overall training satisfaction score rating (P < .001)(Table 2). Domain score effects on overall satisfaction varied for the four different domains, but they were rank-ordered similarly by medical students and residents. For medical students and residents, the learning environment domain had the largest association with overall training satisfaction score. The learning environment domain score’s impact on the overall training satisfaction score was higher for physician residents than for medical students, although this difference did not achieve statistical significance.
Association of items of domain score
We calculated the scores for the individual items in each domain and the effects of the individual items of each domain on the overall domain score (Table 3). Results were analyzed separately for medical students and for residents; we report the difference in each item’s effect on the overall domain score by respondent. After correcting for differences in the distribution of medical students and residents by VA facilities and survey year, medical students assigned higher domain scores than residents for learning environment and working environment (P < .001). Analysis showed that the satisfaction ratings for the majority of items in each of the domains were highly correlated with the overall domain score for medical students as well as residents.
The key items contributing to the learning environment domain score were preparation for future training and quality of care. The impact of the quality-of-care item on the learning environment domain score was higher for physician residents than for medical students, although this result did not achieve statistical significance (P = .002). The quality and teaching ability of clinical faculty were key items determining the clinical faculty/preceptor domain. Work space, peer group and faculty morale, and facility maintenance upkeep and cleanliness were important items for both residents and medical students for the working environment and the physical environment domains, respectively.
Medical students reported a higher percentage of very satisfied responses to the domain scores (learning environment, clinical faculty/preceptor, working environment, and physical environment). When we evaluated the individual items within each domain, the medical students rated 51 of the 53 items higher compared with residents ’ responses. The percentage of very satisfied responses for the approachability/openness and accessibility/availability items in the clinical faculty/preceptor domain was lower for the medical students than for the physician residents (see Appendix 1).
Three key observations can be made from our findings. First, the reported level of trainee satisfaction was higher for medical students than for residents in a common training environment, with differences in satisfaction occurring as medical students and residents advanced in their training while in a common training environment. Second, the domains and items associated with the overall satisfaction with VA-based training of medical students and physician residents were similar. Third, the learning environment domain rating had the strongest association with learners’ overall training satisfaction, whereas ancillary matters associated with the physical environment were found to be less important. The associations found were very similar for both medical students and residents. In the learning environment and clinical faculty domains, the quality of care and quality of faculty were the most important items.
These findings are important because, to our knowledge, ours is the first study to simultaneously compare multiple domains of trainee satisfaction in a common clinical training environment through a serial cross-sectional national survey of medical students and residents. The LPS is a comprehensive satisfaction survey that permits evaluation and comparison of perceptions of clinical training experiences across the entire continuum of medical education. This six-year summary analysis of the LPS shows that, while varying in the degree of satisfaction, the basis for medical students’ and residents’ perceptions of their VA training was very similar overall. Although overall satisfaction was highest among medical students, overall satisfaction varied across the continuum of medical education. Satisfaction was highest early in medical school and lowest during the first postgraduate year of residency.
Much of the literature on both medical student and resident physician satisfaction has focused on individual teachers’ behaviors and styles1,5–7 as important measures of educational effectiveness. Unlike other surveys of trainee perceptions, the LPS looks beyond the role of teaching and role models in evaluating satisfaction with clinical training. Learning environment (hands-on, clinical training), working environment (support, ancillary staff and equipment), and physical environment domains are all incorporated into the LPS. Our results suggest that, at least in the VA setting, the learning environment has the greatest influence on learners’ overall training satisfaction, and the physical environment, working environment, and clinical faculty domains are less important. Although medical students’ and residents’ perceptions were similar, the effect of the learning environment domain on the overall satisfaction score was higher for residents. While this difference approached statistical significance, the contribution of the learning environment domain on medical students’ overall training satisfaction score may be limited by the “ceiling effects” of the higher medical student overall training satisfaction scores.
Previous studies have suggested that many individual items measured by the LPS’s working environment domain and clinical faculty/preceptor domain are important to medical students’ and resident physicians’ satisfaction with their clinical education.1–3,5–7 Items within the LPS’s learning environment domain such as autonomy, supervision, and spectrum of patient problems have also been asso-ciated with learners’ satisfaction.1,3,8–11 The LPS data further suggest that the satisfaction of medical students and physician residents with the learning environment is significantly influenced by the perceived quality of health care provided at the facility. VA health care has changed dramatically in the last decade, with documented improvements in the quality of care as reflected in a broad range of performance measures, such that currently, the VA mostly exceeds private-sector performance.12,13 The data we have presented here may indicate that medical students and residents recognize the VA’s improvement in quality indicators. In a broader sense, quality of care may be an underappreciated item in medical students’ and resident physicians’ satisfaction with their training. Given their direct, daily, hands-on patient contact, medical students and residents may be uniquely positioned to perceive and assess the quality of care delivered in the clinical environments where they work.
Learning theory and previous studies suggest that trainees at different levels may have different learning needs.1 Less is known about the effects of the learning environment and its relative contribution to trainee satisfaction at various levels of medical education. One study in ambulatory teaching sites demonstrated that medical students and residents from five medical schools in Ontario differed in their perceptions of what enhanced their ambulatory training experience.1 Rating the importance of “site characteristics” and “preceptor behaviors” to their learning, medical students more highly valued preceptor interactions (effective teachers, readily available preceptors, opportunity to observe preceptor), whereas residents valued patient mix and practice logistics (adequate number and variety of patients, opportunity to see patients independently). This LPS-based observation suggests that clinical aspects of the learning environment were more important to residents. In a recent study from the United Kingdom,14 medical students assigned to traditional teaching hospitals were compared with students at other types of hospitals. Students were more satisfied with the teaching at the traditional hospitals but more satisfied with the clinical and practical environment at the nontraditional hospitals. Specific practice environment items that were more valued by medical students included the spectrum of problems, opportunity for hands-on experience, and practice of clinical skills.14 Our analysis of the LPS’s national sample of trainees suggests that learners at all levels of medical education placed a higher value on the learning environment than on teaching style and behavior. In VA facilities, although learners’ satisfaction with clinical faculty was very high, the learning environment, adjusted at a facility level, contributed most to the overall training satisfaction score. Prior work1,14 has a limited and varied description of learning environment. The comprehensive development of the LPS has brought further clarity to the content of this important domain. Furthermore, items used to evaluate the perceptions of the learning environment domain, as described in this study, should be taken into consideration in assessing overall training satisfaction in other types of hospitals, settings, and training years.
The results for overall satisfaction as measured by the LPS showed significant differences in satisfaction by level of training. More advanced medical students were less satisfied than first-year students, whereas PGY1 through PGY3 residents were less satisfied than more advanced PGY4 through PGY7 residents. The overall satisfaction differences by training year may represent a reflection of what is known about medical trainee mood and attitude changes through the course of their training. Cynicism seems to increase among medical students, decline during residency, and reach its lowest point among attending physicians.15 Third-year medical students as well as interns have a loss of idealism during training.16,17 Attitude and mood changes affect medical students and physician residents, with improvements towards the end of their training.18,19 These findings lend face validity to the LPS overall satisfaction measure and demonstrate the value of serial administration of the survey across all levels of medical training. Further analysis of these trends and their impacts on the survey domains and items may lead to a better understanding of trainees’ perceptions and needs at various levels of medical education.
Our findings may provide direction to organizations that are interested in improving trainee satisfaction. The VA is an organization with a stated commitment to the education of health care professionals, and, as such, it is invested in making strides in the improvement in its trainees’ satisfaction. Improvements in the learning environment, especially quality of care, while challenging, are more likely to result in larger increases in trainee satisfaction then modifications to the physical environment (e.g., parking and food services).
This study has several limitations. The first limitation was the relatively low response rate of the LPS. No registry existed to identify all potential respondents, so the size of the target populations can only be estimated. The limited penetration raises the issue of sampling bias. Fortunately, from 2002 to 2004, questions identical to those included in the LPS were included in the fourth-year medical students’ questionnaire by the Association of American Medical Colleges (AAMC), which has a response rate of 97%. The value of the VA clinical training experience was rated similarly by fourth-year students in both the AAMC questionnaire (72%–73% rating of exce-llent or very good) and LPS (73%–78% rating of excellent or very good). Thus, on the basis of a comparison with the AAMC questionnaire, our findings indicate that the fourth-year medical students responding to the LPS were representative of fourth-year medical students in general.
A second limitation is that the survey evaluated the most recent VA clinical training experience and does not distinguish between the medical student training specialty or setting (i.e., medicine versus surgery, or outpatient versus inpatient). Although data are available for the specific disciplines of physician resident specialty, we elected to compare students against the entire pool of postgraduate trainees rather than adjust for training program. Important differences in the perceptions of medical students in different clinical settings and physician residents in different specialties may exist, but these could not be explored in our present analysis.
Additionally, the data do not permit analyzing the responses of an individual respondent over time. Because data were collected anonymously through annual surveys, the longitudinal experience of individuals and the impact of repeat respondents cannot be determined.
Finally, the LPS data are limited to the description of associations between the perceptions of respondents and their clinical training at a VA medical facility. Commonalities in the care provided in VA facilities are an advantage to our study because they allow comparisons across training sites; however, the generalizability of findings related to VA training to other training sites may be limited. Nevertheless, one could safely assume that the same factors which influence the satisfaction or dissatisfaction of medical students and residents would be the same regardless of the clinical setting.
In conclusion, medical students and resident physicians expressed high levels of satisfaction with their VA clinical training, with medical students giving higher ratings than residents. The factors contributing to overall satisfaction are remarkably similar for medical students and residents. Whereas the clinical learning environment is the domain most strongly correlated with the overall training satisfaction score, the other three domains—clinical faculty/preceptors, working environment, and physical environment—were important, suggesting that efforts to improve learners’ satisfaction should incorporate all aspects of the clinical training experience. Future work that focuses interventions on key factors associated with trainee satisfaction, as described in this study, is likely to find improvement in the satisfaction of both medical students and residents. Finally, while optimizing trainee satisfaction is important, understanding the linkage between satisfaction and competence warrants further study.
The authors wish to acknowledge the members of the Learners’ Perceptions Advisory Committee and the dedicated staff in the Office of Academic Affiliations that together created and implemented the VA’s Learners’ Perceptions Survey. Special thanks go to VA Office of Academic Affiliations staff members Dilpreet Singh, MS, MPA, Evert Melander, MBA, David Bernett, Terry Kruzan, and Ed McKay.
Other members of the Learners’ Perceptions Working Group: John M. Boyle, PhD, Schulman, Ronca & Bucuvalas, Inc., Silver Spring, Md; C. Richard Buchanan, DMD, FICD, Department of Veterans Affairs, Washington, DC, and University of the Pacific School of Dentistry, San Francisco, Calif; Christopher T. Clarke, PhD, VA Medical Center and St. Louis University, St. Louis, Mo; Stephen J. Dienstfrey, MA, MBA, Schulman, Ronca & Bucuvalas, Inc., Silver Spring, Md; Sheila C. Gelman, MD, VA Health Care System of Ohio, Department of Veterans Affairs, Cincinnati, Ohio; Stuart C. Gilman, MD, MPH, Department of Veterans Affairs and Long Beach Department of Medicine, University of California, Irvine, Calif; Mark Graber, MD, VA Medical Center, Northport, NY, and Department of Medicine, SUNY at Stony Brook, NY; Charles G. Humble, PhD, Office of Quality Improvement, Department of Veterans Affairs, Morrisville, NC; Linda D. Johnson, PhD, RN, Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC; Catherine P. Kaminetzky, MD, MPH, Durham VA Medical Center and Department of Medicine, Duke University Medical Center, Durham, NC; Mark Meterko, PhD, VA HSR&D Management and Decision Research Center, Boston, Mass; Don D. Mickey, PhD, VA Medical Center, Durham, NC; Gary Nugent, VA Medical Center, Omaha, Ne; and Antonette M. Zeiss, PhD, VA Palo Alto Health Care System, Palo Alto, Calif.
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