L’objectif de la thèse est de parvenir à élaborer un modèle d’acquisition de la compétence du médecin. La question de recherche a été libellée ainsi : quelles implications peuvent avoir les expériences professionnelles, la vie quotidienne, les échanges entre pairs, enfin, tout ce qui peut correspondre à des ressources pédagogiques dites « informelles» dans l’amélioration des compétences professionnelles des étudiants en médecine et des médecins. J’ai fait l’hypothèse suivante : dans tout apprentissage, il y a du formel et de l’informel. Et cet informel pourrait être repéré dans un dispositif pédagogique de type coopératif, expérientiel et réflexif ; le contexte d’apprentissage « informel» et « non formel » a certainement un rôle dans l’acquisition des connaissances et des compétences des professionnels de santé.Trois dispositifs pédagogiques fréquemment utilisés au cours du 3e cycle de la formation initiale des médecins et en formation médicale continue ont été proposés à des étudiants en médecine et des médecins installés en milieu ambulatoire. De tels dispositifs basés sur la mobilisation de l’expérience, la réflexion et la coopération entre les participants seraient susceptibles de contribuer à l’amélioration de la compétence des étudiants en médecine et des médecins.Il existe, dans chacun des dispositifs d’apprentissages éprouvés, et en tenant compte des cadres de références et des connaissances propres à chaque participant, des savoirs formels et informels. Ces savoirs ont contribué dans leur globalité à la transformation des apprenants. Cependant, la distinction entre ces deux modes d’apprentissages formels,informels est surtout théorique. Elle est notamment fonction des lieux et des moments où ces apprentissages ont été dispensés. Il existe en réalité un véritable continuum entre ces différents apprentissages. / This thesis attempts to offer a model for the acquisition of knowledge and skills amongphysicians. The research undertook to explore the role of professional experiences, dailylife, exchanges between peers, and all other forms of so-called « informal » learning inenhancing the professional skills of medical students and physicians. The author laboredunder the following hypothesis: all learning involves both formal and informal aspects,and the informal aspects can be found in cooperative, experiential and reflexive typepedagogical constructs. Finally, « informal » and « non-formal » learning opportunitiescertainly play a role in the acquisition of knowledge and skills among health care professionals.Three teaching mechanisms frequently used during the 3rd cycle of initial medical trainingas well as in medical continuing education programs were made available to medicalstudents and physicians working in ambulatory setting. These tools, which encourageparticipants to marshal their own experiences, to reflect thoughtfully and to cooperatewith each other, can improve the skills of medical students and physicians.Each of the three teaching mechanisms studied herein, factoring in individual backgroundsand proficiencies, contain both formal and informal knowledge and skills which,as a whole, contributed to the transformation of the participants. However, it is importantto note that the distinction between formal and informal learning is primarily theoretical,and may simply depend on context or location. Therefore, rather than opposethem, it may be more appropriate to consider that these types of learning lie on a continuum.

Traditionally, medical residency positions have been primarily funded by the federal government. However, due to declining governmental funding support over time, medical schools have resorted to fund these programs through other means such as clinical fees and payments for services. This change has affected the number and types of residencies available to medical school graduates. The purpose of this study was to measure how the availability of fiscal resources shape mission-related outputs, particularly medical residency positions at medical schools. Using academic capitalism as the theoretical framework provided a lens through which to examine how federal policies have shaped the availability and funding of medical residencies today at the institutional level. This concept has been studied in traditional colleges and universities and how they balance mission and money, but less so in the context of medical schools. This study used a fixed effect panel analysis to study the impact of selected variables over a 10-year period on financing of medical residencies. Findings included that tuition revenues, paid for by undergraduate medical students, are increasingly funding medical residency positions. There was little to no effect from hospital revenues and federal research monies on increasing the number of medical residency positions. The funding of university based medical education is particularly timely and of national importance to understand the consequences of federal policies for medical schools and how medical residency funding caps and limits have affected one of the missions of medical schools which is to train physicians.

Indiana University-Purdue University Indianapolis (IUPUI) / The anatomical sciences are experiencing a notable decrease in the time and resources devoted to embryology in North American medical education. With more changes assured, it is necessary to investigate the current trends in curriculum, pedagogy, and related experiences of embryology teachers and learners. To address these concerns, the researcher developed two online mixed methods surveys: one for current anatomy and embryology faculty and another for first year medical students. The faculty survey was followed by interviews with volunteers from that cohort. The researcher used a grounded theory methodology to analyze the qualitative components of the surveys, and descriptive statistics to analyze the quantitative components of the surveys. Both the faculty and student surveys illuminated the vast differences between the explicit, implicit, and null curricular components found in the numerous medical education programs represented. A combined grounded theory methodology and phenomenological approach was used to analyze the interviews with faculty. This generated a lived experience narrative of the phenomenon of teaching embryological content to medical students in the modern world, which led to a better understanding of the needs and challenges that face this subject matter and those who teach it. In this fluid era of medical education reform and integration, the perceptions and experiences of anatomy and embryology faculty and first year medical students are invaluable to assessing the curriculum and pedagogy of this foundational anatomical science and formulating evidence-based recommendations for the future.

No description available.

This paper describes an empirical approach to assessing pediatric residents' attitudes, knowledge and skills in primary care behavioral health. Outcomes from that assessment approach are presented from two pediatric residency training programs in the northeastern United States. Thirty-six pediatric residents completed attitudes, knowledge and skills surveys. The survey was developed to align with the American Academy of Pediatrics’ Policy Statement in 2009 citing aspirational competencies for pediatricians in primary care behavioral health. This alignment addressed both learner variables (attitudes, knowledge, and skills) as well as clinical presentations (ADHD, anxiety, depression, and suicide) highlighted in the policy statement. The survey specifically inquired about self-reported confidence and comfort in managing behavioral health concerns using evidence-based practice parameters (attitudes and knowledge) and their measured ability to deliver evidence-based care in response to clinical vignettes (skills). Findings largely revealed no statistically significant differences in attitudes, knowledge or skills between interns and upper-level residents. Training programs can use the approach described in this paper and the assessment instrument with some possible modifications to monitor annual progress and evaluate any changes in didactic and clinical training.

<p>Focus of Thesis This thesis focuses on the initial stages of developing the Ontario Decision Aid in Rectal Cancer for Stage II and III patients (ODARC). The ODARC is a DA meant to facilitate relevant information exchange among physicians and patients. Such a tool should enhance patient knowledge and accuracy of treatment expectations by effectively conveying to patients relevant information on treatment options and associated benefits and risks. The ODARC is designed for use during a physician-patient consultation. The ODARC prototype development was guided by a workbook on developing & evaluating patient DAs published by O’Connor & Jacobsen (for efficiency we will call this the Workbook).24 This latter document provides detailed instructions for a 7-step DA development process including: 1) assess patient and provider need 2) assess DA feasibility 3) define objectives of the DA 4) identify the framework to guide DA development 5) select tailored methods of decision support to be used in the DA 6) select the designs and measures to evaluate the aid and, 7) plan dissemination.24 In this thesis we have created a prototype ODARC as informed by Steps 1 to 5 of the Workbook. The last two steps covering evaluation and dissemination are beyond the scope and available resources of this current research effort, and can be considered as future research endeavours. This will be reviewed in the final chapter.</p> / Master of Science (MSc)

Yes / Team-based learning is an active learning strategy that focuses on student’s engagement, development of critical thinking, and transferable skills needed in the workplace. While many pharmacy faculties around the world have applied team-based learning into their curriculums, the implementation of team-based learning into the Middle East is still in the experimental phase and poses its own challenges. This reflective statement elaborates on our experience and feedback of implementing team-based learning for the first time at the pharmacy faculty of Zarqa University in Jordan through the delivery of over-the-counter module.

UA Open Access Publishing Fund / Study objectives: Multiple curricula have been designed to teach medical students the basics of ultrasound; however, few focus on critical problem-solving. The objective of this study is to determine whether a theme-based ultrasound teaching session, dedicated to the use of ultrasound in the management of the hypotensive patient, can impact medical students’ ultrasound education and provide critical problem-solving exercises. Methods: This was a cross-sectional study using an innovative approach to train 3rd year medical students during a 1-day ultrasound training session. The students received a 1-hour didactic session on basic ultrasound physics and knobology and were also provided with YouTube hyperlinks, and links to smart phone educational applications, which demonstrated a variety of bedside ultrasound techniques. In small group sessions, students learned how to evaluate patients for pathology associated with hypotension. A knowledge assessment questionnaire was administered at the end of the session and again 3 months later. Student knowledge was also assessed using different clinical scenarios with multiple-choice questions. Results: One hundred and three 3rd year medical students participated in this study. Appropriate type of ultrasound was selected and accurate diagnosis was made in different hypotension clinical scenarios: pulmonary embolism, 81% (95% CI, 73%–89%); abdominal aortic aneurysm, 100%; and pneumothorax, 89% (95% CI, 82%–95%). The average confidence level in performing ultrasound-guided central line placement was 7/10, focused assessment with sonography for trauma was 8/10, inferior vena cava assessment was 8/10, evaluation for abdominal aortic aneurysm was 8/10, assessment for deep vein thrombus was 8/10, and cardiac ultrasound for contractility and overall function was 7/10. Student performance in the knowledge assessment portion of the questionnaire was an average of 74% (SD =11%) at the end of workshop and 74% (SD =12%) 3 months later (P=0.00). Conclusion: At our institution, we successfully integrated ultrasound and critical problemsolving instruction, as part of a 1-day workshop for undergraduate medical education

Thesis (DPhil)--University of Stellenbosch, 2004. / ENGLISH ABSTRACT: In this thesis, an ‘alignment approach’ to the quality assurance of medical curricula is developed and practically illustrated in the evaluation of a section of a new curriculum in undergraduate medical education and training instituted at the Faculty of Health Sciences of the University of Stellenbosch in 1999. The background of curriculum innovation at this institution during the 1990s is described, and the literature on the concepts of quality assurance is explored in higher education in general and in medical education and training in particular. The current focus on socially responsive curriculum renewal and accountability illustrates the need for this study. The empirical part of the study was conducted in two phases. The first phase consisted of a ‘clarification evaluation’. The planning of the new curriculum introduced in 1999 was analysed retrospectively through a study of the planning documents and interviews with leaders of the planning process. The results of this clarification evaluation are presented in the form of a ‘Logic Model’. The implicit theory of the curriculum, as represented by the Logic Model, was then evaluated regarding its consistency with trends in medical education. These trends were determined through a study of the literature on the subject published during the time of the planning of the curriculum. It was found that the planning of the curriculum was in line with most of the identified trends, but that it lacked detailed information on how the basic sciences and clinical skills training were to be addressed. This compromised the evaluability of phase I of the curriculum and of the clinical rotations1 by the method use in this study. Because of this, and also considering the time frame of this evaluation, phase I of the curriculum and the late clinical rotations were excluded from the second phase of the study. The aims identified for the curriculum during the process of clarification evaluation were also aligned with the document, The Profile of the Stellenbosch Doctor 2 . This indicates that the planning process of the curriculum was in line with its intended outcome.The second phase of the study consisted of an ‘implementation evaluation’ of phases II and III of the theoretical components and of the early and middle clinical rotations of the curriculum. Data for this implementation evaluation were collected from April 2002 to June 2003. Module chairpersons3, lecturers and students were used as sources of data for the evaluation of the theoretical phases. The perceptions of these groups regarding the implementation of phases II and III of the theoretical part of the curriculum were collected by means of questionnaires designed specifically for this study. For the evaluation of the clinical rotations, the results of the standard student feedback obtained by the Faculty of Health Sciences were used as a source of data for a secondary analysis. The study guides provided for each of the theoretical modules and the clinical rotations were also used as a secondary source for the analysis of data. The data obtained were then analysed by using the framework provided by the Logic Model. Following this, a judgment of the quality of the implementation of the curriculum was made. The planned curriculum was aligned with the practised curriculum by drawing up a ‘curriculum scoreboard’. It was found that alignment was adequately achieved for six of the identified aims, while the implementation of four of the aims was not aligned to the planning according to the criteria used in this study. The study illustrates that the methods of programme evaluation can be validly applied in the evaluation of a curriculum in medical education and training. The Logic Model enables an alignment between the planned and the practised curriculum, which can be used as a measure of the quality of a curriculum in terms of ‘fitness of purpose’. 1 See Addendum A for a diagrammatic overview of the curriculum. The curriculum was structured into three theoretical phases (phases I, II and III) and three clinical rotations (early, middle and late). 2 This document was drawn up during the initial phases of the planning process of the curriculum and regarded by the Faculty as a blueprint for the intended outcomes of the curriculum. 3 A module chairperson in the context of the Faculty of Health Sciences of the University of Stellenbosch is a senior faculty member responsible for the organisation and management of the modules presented as part of the curriculum in medical education and training. / AFRIKAANSE OPSOMMING: In hierdie tesis word ʼn ‘belyningsbenadering’ tot die gehalteversekering van mediese kurrikula ontwikkel en prakties op die proef gestel deur ʼn gedeelte van die nuwe kurrikulum vir voorgraadse mediese onderrig, wat in 1999 aan die Fakulteit Gesondheidswetenskappe van die Universiteit van Stellenbosch ingestel is, te evalueer. Die agtergrond van kurrikulumverandering in hierdie instansie gedurende die 1990’s word ondersoek, en daar word ’n oorsig gegee van die literatuur oor die konsepte van gehalteversekering wat op daardie stadium in die hoër onderwys in die algemeen en in mediese onderrig in besonder in gebruik was. Die huidige fokus op sosiaal responsiewe kurrikula en verantwoordbaarheid illustreer die noodsaaklikheid van ʼn studie van hierdie aard. Die empiriese gedeelte van die studie is in twee fases uitgevoer. Die eerste fase het bestaan uit ‘n ‘verklarende evaluasie’. Die beplanning van die 1999-kurrikulum is retrospektief geanaliseer deur die bestudering van die relevante beplanningsdokumente en deur onderhoude met leiers van die beplanningsproses te voer. Die resultate van die verklarende evaluasie is in die vorm van ʼn ‘Logika Model’ voorgestel. Die implisiete teorie van die kurrikulum, soos voorgestel in die Logika Model, is daarna geëvalueer ten opsigte van die ooreenstemming van die model met die tendense in mediese onderrig wat op daardie stadium geldig was. Hierdie tendense is nagespeur in die belangrikste literatuur oor die onderwerp wat in dieselfde tydperk as die beplanning van die 1999-kurrikulum gepubliseer is. Die bevinding was dat die beplanning van die kurrikulum in lyn is met die meerderheid geïdentifiseerde tendense, maar dat die basiese wetenskappe en opleiding in kliniese vaardighede nie in detail aangespreek is nie. Dit het die evalueerbaarheid van fase I van die kurrikulum en die kliniese rotasies4 deur die metode wat in hierdie studie gebruik is, gekompromitteer. Om hierdie rede, en met inagneming van die tydsraamwerk van hierdie evaluasie, is fase I en die laat kliniese rotasies nie in die tweede gedeelte van hierdie studie ingesluit nie. Die doelwitte van die kurrikulum wat gedurende die verklarende evaluasie geformuleer is, is ook met die dokument, Die Profiel van die Stellenbosch dokter 5, belyn. Dít het aangedui dat die beplanningsproses van die kurrikulum in lyn met die beoogde uitkoms daarvan is.Die tweede deel van die studie het bestaan uit ʼn ‘implementerings-evaluasie’ van fases II en III van die teoretiese komponente en van die vroeë en middel kliniese rotasies van die kurrikulum. Data vir die implementerings-evaluasie is vanaf April 2002 tot Junie 2003 ingesamel. Modulevoorsitters6, dosente en studente is as bronne van data vir die evaluering van die teoretiese fases gebruik. Die indrukke van hierdie groepe persone betreffende die implementering van die teoretiese fases is deur middel van vraelyste ingesamel wat spesiaal vir hierdie studie ontwerp is. Vir die evaluering van die kliniese rotasies is die resultate van die standaard studenteterugvoer wat deur die Fakulteit ingewin word, gebruik as bron vir sekondêre analise. Die studiegidse wat vir elke teoretiese module en die kliniese rotasies verskaf word, het ook as ʼn bron vir sekondêre data-analise gedien. Die data wat vir hierdie studie ingewin is, is deur middel van die raamwerk wat deur die Logika Model verskaf is, geanaliseer. Daarna is ʼn oordeel gevel oor die kwaliteit van die implementering van die kurrikulum. Die kurrikulum-soos-beplan is belyn met die uitgevoerde kurrikulum deur ’n ‘kurrikulumtelbord’ op te stel. Die bevinding was dat hierdie belyning voldoende bereik is vir ses van die geïdentifiseerde doelstellings van die kurrikulum, terwyl die uitvoering van vier van die doelstellings nie goed met die beplanning daarvan belyn was volgens die kriteria wat vir hierdie studie gebruik is nie. Hierdie studie illustreer dat die metodes van programevaluasie geldig toegepas kan word in die evaluering van ’n kurrikulum in mediese onderrig en opvoeding. Die Logika Model maak dit moontlik om die beplande kurrikulum met die uitgevoerde kurrikulum te belyn. Dit kan dan gebruik word as ’n maatstaf van die kwaliteit van ’n kurrikulum in terme van ‘geskiktheid vir doel’.4 Sien Addendum A vir ʼn diagrammatiese oorsig van die kurrikulum. Die kurrikulum is gestruktureer volgens drie teoretiese fases (fases I, II en III) en drie kliniese rotasies (vroeg, middel en laat). 5 Hierdie dokument is gedurende die vroeë fases van die beplanningsproses van die kurrikulum saamgestel en word deur die Fakulteit as ʼn bloudruk vir die beoogde uitkomste van die kurrikulum beskou.6 ’n Module-voorsitter in die konteks van die Fakulteit Gesondheidswetenskappe van die Universiteit van Stellenbosch is ʼn senior lid van die fakulteit wat verantwoordelik is vir die organisasie en bestuur van die modules wat as deel van die kurrikulum in mediese onderrig en opleiding aangebied word.

Thesis (MPhil)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background - The College of Phycians and Surgeons Pakistan (CPSP) was established in 1962 and its role is to oversee the postgraduate medical education within Pakistan. At present, various specialties belonging to the CPSP carry out quality assurance visits including evaluation of the learning environment of the teaching hospitals by asking the supervisors and doctors in training about the qualification and experience of supervisors, equipment, library, infrastructure and type of work load. The CPSP do not make use of a valid and reliable method when performing these assessments and therefore there is a need for the CPSP to develop a standardized method of assessing the learning environments of the teaching hospitals in Pakistan. This method needs not only to be valid and reliable but also reproducible and transferable so that it can be used to measure the learning environments in various departments and teaching hospitals .It can further be used to compare the learning environments across different teaching hospitals and specialties with in Pakistan. The learning environment of teaching hospitals of Pakistan have not been studied before therefore the purpose of this study was to measure the postgraduate learning environment of private and public sector teaching hospitals of twin cities in Pakistan Islamabad and Rawalpindi .Public sector hospitals are fully funded by the government of Pakistan and patients receive free treatment, while private hospitals are commercial hospitals where everything is paid by patients. Following the postgraduate educational environment measurement results between house officers and residents working in the above mentioned environments was then compared. These results can inform supervisors and institutions about short comings as well as strong points with regards to the learning environment. Materials and Methods After approval from the Shifa International Hospital`s Ethical committee and Health Research Ethical committee of the University of Stellenbosch, and informed consent were obtained from research participants. The Postgraduate Hospital Educational Environment Measurement questionnaire (PHEEM) was administered to the house officers and residents of six public and one private sector teaching hospital of twin cities (Islamabad and Rawalpindi) in Pakistan with the help of the supervisors of CPSP based at these hospitals. The PHEEM was completed during their respective teaching sessions at the various hospitals .The supervisors was asked to encourage students to complete the PHEEM questionnaire .Supervisors were instructed to collect the completed questionnaires the from doctors in training at their individual hospitals and then send it back using the enclosed envelope The PHEEM contains of 40 items covering a range of issues directly related to the clinical learning environment of house officers and residents1. These statements make up 3 subscales of the clinical learning environment namely autonomy, social support and teaching. Autonomy (such as the quality of supervision) is represented by 14 statements teaching (the qualities of teachers by 15 statements and social support (such as facilities and atmosphere) by 11statements. Each of the 40 statements can be rated from 0-4 .The respondents are asked to indicate their agreement using a 5 point Likert scale .These range from strongly agree(4) ,agree(3), unsure(2), disagree(1) to strongly disagree (0). Agreement with the items indicates a positive learning environment and will result in high scores. The maximum possible scores are 56 for autonomy, 60 for teaching, 44 for social support and an overall score of 160.It is essential that each junior doctor applies the items to their own current learning place1. - Statistical analysis - The statistical analysis was conducted by using SPSS 16.0 and the four negative items were scored in reverse (question 7, 8, 11, 13). The scores for the total as well as the sub-scales were described by using means and standard deviations (SD). Comparisons of the perception of the educational environments between house officers and residents were expressed as a mean and ± SD and its statistical significance was determined by student t- tests. A p value ≤ 0.05 was considered statistically significant. The results from the three construct of the PHEEM survey were compared among the house officers and residents from surgery, medicine, pediatrics and Obstetrics’ and Gynecology by ANNOVA and post hoc sidak test. A p value ≤ 0.05 was considered statistically significant. - Results - The internal reliability of the questionnaire was good with a total Cronbach`s Alpha value of 0.92 (a Cronbach`s alpha of more than 0.7 or 0.8 is accepted as being good). The questionnaire further revealed Crobach`s alpha value of 0.78, 0.89 and 0.70 for the various subscales of autonomy, teaching and social supports .When this was analyzed to exclude each question in turn, using the alpha if deleted there was no significant improvement in the score, thus confirming all questions were relevant and should be included. A total of 286 out of 300 (95.33% response rates) house officers and residents belonging to the seven different teaching hospitals of twin cities of Islamabad and Rawalpindi, Pakistan participated in the study. The PHEEM questionnaire was completed by all the participating doctors composing of 51% house officers and 49 % residents .Both genders were almost equally represented in the two groups comprising of 52% male and 48% female doctors. The distribution of male and female gender is different among respondents from various specialties. There was 23.60% male and 15.03% females in surgery, 22.20% males and 18.30% females in medicines, 6.20% males and 4.32% females in Pediatrics and 10.33% females in obstetrics. House officers and residents belonging to all major specialties took part in the study with the distribution looking as follows, Medicine 44.8%, Surgery 33.6% Obstetrics and Gynecology11.2% and Pedriatics10.50%. The mean score (M) and the standard deviation (SD) for each of the subscale namely the perceptions of autonomy, teaching and social support of house officers and residents are shown Table number 1 (Autonomy), Table number 2 (Teaching) and Table number 3 (Social support) respectively. These tables also show the mean of the total scores of each subscale. The lowest recorded score was 1.37 for question number 4.Question number 1, 4,5,9,11,17 and 32 with in the autonomy section were found to have a relatively low rating as shown in table number 1. Teaching quality questions 3, 21 and 33 showed a low rating as demonstrated in table number 2. Social support showed a low rating for question number 19, 20, 25, 26, 36 and 38 again shown in table number 3. The results from the three subscales of the PHEEM survey were compared between residents and house officers from the teaching hospitals of the twin cities are shown in Table number 1, 2, and 3 respectively. The perception of autonomy was higher amongst residents with a mean of 28.74 compared to house officers 28.27. The difference, however, was not statistically significant between the two groups but there was a statistically significant difference between the two groups in question number 32, where the residents perceived that work load for them was better than house officers. It seems as the residents have better opportunities to access and participate in educational events and programs compared to the house officers seeing that there was a statistically significant difference in question numbers 12 and 21 respectively as shown in table number 1. The perceived level of quality of teaching was higher for residents with mean of 32.02 as compared to the house officers with a mean of 31.12. However this difference was not statistically significant as shown in table 2. The perception of social support was high amongst house officers with a mean of 19.66 compared to residents with a mean of 19.06. There was statistically no difference between the two groups regarding the social support provided at these teaching hospitals; however the house officers felt physically more save compared to residents as shown in table 3 Regarding the difference between private and public sector hospitals, the mean score of the three subscales of the PHEEM, namely the mean score for the perception of autonomy (28.71 vs. 27.14, p=0.24) teaching (33.08 vs. 32.37, p=0.25) and social support (21.94 vs. 21.22, p=0.24) were not statistically significant. The results from the three subscales of the PHEEM survey were compared amongst the junior doctors from Surgery, Medicine, Pediatrics and Obstetrics’ and Gynecology by ANNOVA and post hoc sidak test. There was no statistically significant difference among these junior doctors in the majority of the PHEEM questions. For question number 4, I had an informative induction programme, there was statistically significant difference between the junior doctors of medicine and obstetrics & gynecology .Regarding the question number 5, I had appropriate level of responsibility in this post, and there was statistically significant difference between junior doctors of surgery & pediatrics and surgery and obstetrics & gynecology. There was significant difference between the junior doctors of medicine and Obstetrics and gynecology for question number 29, I feel part of the team working here. Regarding perception of question number 30, I have opportunity to acquire the appropriate practical procedures for my grade; there was significant difference between the junior doctors of obstetrics & gynecology and surgery. For perception of teaching, there was a significant difference between the junior doctors of medicine and obstetrics & gynecology in the following questions. Question number 10: my clinical teachers have good communication skills; Question number 23: my clinical teachers are well organized; and question number 27: I have enough clinical learning opportunity of my needs. In the subscale of social support there was a significant difference for item number 13 which states that there is sex discrimination in this post between the junior doctors of surgery and pediatrics .The junior doctors from medicine perceive that there was more calibration among the doctors of medicine as compared to pediatrics. - Discussion and conclusion - This study shows that the PHEEM questionnaire consists of a practical, reliable and simple set of questions to measure the learning environment of doctors in training at teaching hospitals of Pakistan; a country which is socially, culturally and economically different from the country where this questionnaire was originally constructed. This could imply that the perceptions of doctors in training are similar regardless of geographical boundaries and economic conditions of the country where they live. . Other studies that employed PHEEM in different parts of the world show similar scores. This study does not show a statistically significant difference between house officers and residents in terms of teaching, role of autonomy and social support. The reasons for this may be that house officers and residents share the same infrastructure for accommodation, catering and social support. Furthermore, there is no practically organized structured training programme with a specified job description for doctors at different levels of training. This study therefore does not confirm results of the studies performed in United Kingdom and Australia, where house officers experienced a better learning environment than residents in many respects. This study was completed by house officers and residents from private as well as public sector teaching hospitals. We did not find a statistical difference in the level of perceptions between doctors in training working in these two different set up of hospitals. This goes against the common notion present amongst junior doctors that training at public sector hospitals have a higher level of satisfaction due to better and more learning opportunities than at private sector hospitals because in these hospitals independent work is not allowed. The result off this study indicates that the perception level of house officers and residents in training in various specialties was different regarding the learning environment. This difference was even more marked for the specialty of Gynecology and obstetrics where the PHEEM items were scored lessened compared to the other specialties. The reason for this could be due to better training opportunities, more structured and availability of mentors in Surgery, Medicine and Pediatrics compared to the female dominated specialty of Gynecology and obstetrics. The female work and learn in different way because they score three items directly related to perception of teaching lower compare to male dominated specialities. The PHEEM questionnaire results have been taken from seven teaching hospitals of the twin cities, and therefore provide a good overall picture of the learning environments of teaching hospitals in Pakistan seeing that the teaching hospitals of Pakistan almost have similar infrastructure and faculties with few individual variations. This sample represents all major specialties thus provide a good picture of the learning environment for all doctors in training. It is clear that in order to ensure high standards in education and training of junior doctors, the importance of the learning environment cannot be ignored. The following are recommendations for the CPSP so that they take steps in collaboration with administrative and medical staff to improve the learning environments where needed. 1. A meeting between the CPSP and administrative staff should held every year to overcome the weakness pointed out in this study 2. Teaching hospitals should publish an informative junior doctors hand book , with a job description, responsibilities, expectation and information about working hours 3. The junior doctors should have protected time for educational activities 4. The attendance at educational sessions must be supported by the Supervisors of CPSP 5. Career advice and counseling opportunities should be avaible at each regional center of CPSP 6. Accommodation should meet the appropriate standards 7. Good quality hygienic catering facilities should be present around the clock for junior doctors. 8. Each teaching hospital should administer the PHEEM ever year to measure their quality and potentially improve their standards. In conclusion this study shows a great need for the creation of a supportive environment as well as designing and implementing interventions to remedy unsatisfactory elements of the educational environment if effective and successful learning is to be realized by the CPSP.