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.