Original Article
Residents’ Perceptions and Attitudes Regarding the Half-Day Release Course in the Family Medicine Residency Program
Aliyah Muteb Al-Ruwaili1, Umar Farooq Dar2*
1Resident, Boards Family medicine, Directorate of Health, Aljouf Region, and,
2Department of Family and Community Medicine, Jouf University, Sakaka, Saudi Arabia.
*Corresponding author: [email protected]
Abstract
Background: Half-Day Release Course (HDRC) is a 4-hour weekly activity that is conducted throughout the year at a primary care center as compulsory component of Saudi boards family medicine. The residents are exempted from their hospital duties and training and clinic postings to attend the course.
Objective: The aim was to assess residents’ perceptions and attitudes toward a half-day release course (HDRC) during a four-year family medicine residency program in Saudi Arabia.
Participants and Methods: We conducted a cross-sectional analytical study among family residents (n = 418) across Saudi Arabia from November 2018 to May 2019 by using non-probability convenience sampling. Data was collected using a valid and reliable questionnaire comprising 20 questions. We categorized perceptions in three domains (motivation, quality, and perceived benefits) and attitudes in two domains (positive and negative), which were evaluated on a scale of 0 to 5.
Results: In this study, 72% participants were enthusiastic to attend the HDRC, whereas 55% expressed enthusiasm to attend future sessions. Furthermore, 50% and 63%
participants anticipated that their colleagues and supervisors were motivated to attend the course, respectively. Approximately 66% participants stated that the HDRC is advantageous in skill development and catalyzes their improvement. . Moreover, 90%
trainees attended all of the previous four sessions; among which, only 30% provided feedback. Furthermore, 35% participants attended only for marking their attendance.
Mean scores in the domains of motivation, perceived benefits, and quality, mean positive attitude score, and mean negative score were calculated.
Conclusion: The overall perceptions of residents were satisfactory. Thus, we can conclude that HDRC is achieving its aim of motivating the residents for self-directed learning.
Key Words: Academic half day, Family medicine residency, Graduate medical training, Satisfaction among residents, Perceptions toward family medicine training.
Citation: Al-Ruwaili AM, Dar UF. Residents’ Perceptions and Attitudes Regarding the Half-Day Release Course in the Family Medicine Residency Program. AUMJ, June 1, 2018; 5(2): 25 - 31.
Introduction
An adult learning cycle, particularly continuing medical education and self- directed learning, is different from learning through didactic classroom teaching(1,2). Perceptions regarding a particular learning event in terms of quality and perceived benefits increase sustained and continuous learning as well
as learning enthusiasm(3). Different methods, such as noon conferences, journal clubs, academic half days, and half-day release courses (HDRCs), are employed for postgraduate training in family medicine(4-7). Specialization in family medicine is distinct because it includes comprehensive medical care processes from treatment to lifestyle
modifications(6,8). Residents specializing in family medicine must learn local traditions and restrictions, hereditary concerns, and social fabric when treating chronic diseases(8,9). A recent review article from Saudi Arabia highlighted that to train competent family medicine specialists, academic and service aspects must be emphasized(9,10).
The Saudi Commission for Health Specialties (SCFHS) is aiming to focus on the aforementioned aspects through an innovative competency-based residency training in family medicine(11). The HRDC is one of the elements of this training and is mandatory for all family medicine residents(12). The HDRC is a 4- hour weekly activity that is conducted throughout the year at a primary care center. The residents are made available to attend the course by being exempted from their hospital duties and training, and, from clinic postings to attend the course(9,12,13). This course aims to inculcate a self-directed learning behavior on residents, which improves their skills to present and raise scientific queries as well as learn about recent advances in family medicine. A study that evaluated the satisfaction of an HDRC in the Makkah region showed varying levels of satisfaction of residents for different components of the course. The highest and lowest levels of satisfaction were observed for "environment and teaching methods" and for "presenter and presentation", respectively(12). Another study evaluating the overall satisfaction of a training program showed that 35% of the participating trainees were dissatisfied with their training(13). A study evaluating the effectiveness of an academic half day (AHD) in a hematology-oncology fellowship program revealed that the fellows were favorable toward and motivated by it(4).
The conduct of HDRC reflects uniformity throughout the kingdom of Saudi Arabia.
However, the comprehensive analyses of perceptions and attitudes of end-users toward the course are not available. In this study, we aimed to provide evidence to improve HDRC in the family medicine residency program in Saudi Arabia. We conducted this study to understand the
perceptions and attitudes of the residents toward HDRC regarding its relevance and usefulness in their knowledge and skill development. The results of this study can improve the quality of the course and provide possible solutions to the relevant concerns.
Participants and Methods We conducted a cross-sectional analytical survey after the proposal was approved by a local ethical review committee (Approval #023). In this study, the target population was family medicine residents registered with the Saudi Board of Family Medicine in Saudi Arabia. A convenient non-probability sampling technique was used to recruit participants. The calculated sample size was 385 residents (using a sample size calculator by World Health Organization) with an expected 50%
prevalence of a positive attitude towards HDRC among residents at a confidence level of 95% and a margin error of 5%.
Because of the scarcity of the data available in this field, the expected prevalence was considered 50% to obtain the highest sample size. All currently enrolled residents of both genders working in the recognized programs throughout Saudi Arabia were eligible to participate in this study.
We shared a link for a web-based, anonymous questionnaire with eligible participants through different means (e.g., official emails registered with SCFHS and social media groups for different residency levels) from 1November, 2018 to 31May, 2019. We provided sufficient information in a cover letter presented before filling the form regarding the study in a comprehensible language. We followed COPE ethical standards and obtained an informed consent. We received responses from 421 participants;
among them, three forms were omitted because of incomplete data (n = 418).
The utilized data collection tool comprised demographic data (i.e., age, gender, and residency levels) and 20 questions. 10 questions were related to perception with answers ranging from strongly disagree to strongly agree, and the leading question was "how much do you agree with the statement". Further 10 yes or no questions were related to the
attitude toward HDRC. The final questionnaire was assessed for face validity by three educationists (a program director, a family medicine supervisor, and a faculty member at the college of medicine). For content reliability, a pilot study was conducted with 30 residents working in one region. The reliability index was satisfactory - Chronbach's alpha was 0.84.
The perception component comprised three domains, namely motivation (four questions), course quality (three questions), and perceived benefit (three questions), whereas the attitude component had two domains, namely positive (seven questions) and negative (three questions). For all five domains, we calculated average scores on a scale of 0 to 5, where strongly disagree, disagree, true sometimes, agree, and strongly agree were labeled as one, two, three, four, and five, respectively. The scores for each domain were calculated and converted to a scale of 0 to 5 to improve understanding. A higher score in any category indicated higher agreement. For eight attitude questions, yes and no were represented with a score of one and zero, respectively. The residents who had attended all of the four previous sessions were given a score of 2, whereas those who did not attend any of the previous sessions were given a score of 0. Further, residents who had attended some of the previous sessions were given a score of 1.
The same scoring was applied for questions regarding feedback. The summation of the score in all five domains, namely motivation, course quality, perceived benefit, positive attitude, and negative attitude, were presented on a scale of 0 to 5 for comparability.
The data was analyzed using the Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, Version 23.0 Armonk, NY: IBM Corp.).
Mean ± standard deviation (SD) were used to describe continuous variables (scores and age), whereas frequency (n) and percentage (%) were used to describe categorical data (individual perceptions and attitudes). A Chi-squared or Fischer exact test was employed to determine the
difference between categorical variables.
A Levene’s test was used to validate equal variance among comparable groups.
A Mann-Whitney U test and Kruskal Wallis H test was applied for observing significant differences in median scores across two or more categories, respectively. Correlation was evaluated using a Pearson linear coefficient (r) after validating linearity assumptions of the scale through PP and QQ plots. A p value
<0.05 was considered significant.
Results
In the study population (n = 418), 52.2%
participants were female. The mean age of the residents was 28 ± 2 years. The percentage of participants from residency levels 1, 2, 3, and 4 were 34.7%, 29.9%, 24.2%, and 11.2%, respectively. Further, 72% participants were enthusiastic to attend HDRC, and 55% intended to attend the next session. Moreover, 50% and 63%
participants expressed that their colleagues and supervisors were motivated to attend, respectively. In this study, 70% participants agreed that HDRC facilitated skill development, whereas 65% conveyed that the course proposed self-improvement. Table 1 presents the percentages of ten perceptions in the three domains (i.e., motivation, perceived benefits, and quality of course) on a scale from strongly agree to strongly disagree.
Regarding their attitudes toward HDRC, 90% participants attended all of the previous four sessions; however, only 30% participants provided feedback.
Moreover, presentation distribution was fair because 90% participants had presented a topic in 3 months. We found that 35% participants attended for only marking their attendance. Table 2 presents both positive and negative attitudes.
In the three domains of motivation, perceived benefit and quality of the course, on a scale of 0 to 5, the mean motivation, mean perceived benefit, and mean quality scores were 4. Similarly, on a scale of 0 to 5, the mean positive attitude and mean negative attitude scores were 3.5 and 1.1, respectively. Table 3 presents the correlation between motivation, perceived benefit score, and quality of the course.
Table 1: Perception of family medicine residents toward the HDRC (n = 418). Data presented are
%.
How much do you agree with the presented statement regarding the HDRC?
Strongly Agree
Agree True sometimes
Disagree Strongly Disagree 1 I am enthusiastic to attend. 34.0% 37.8% 24.2% 0.0% 4.1%
2 It helps develop my skills. 29.2% 40.0% 22.0% 6.0% 2.9%
3 The selected topics are relevant to my specialty.
37.3% 44.5% 15.8% 1.9% 0.5%
4 Teaching resources (e.g., audiovisual aids) are sufficient.
20.6% 37.8% 30.1% 8.1% 3.3%
5 Learning resources (library, references, and computers) are sufficient.
20.6% 40.2% 19.4% 13.2% 6.7%
6 The other residents (my colleagues) are motivated to attend.
13.2% 36.4% 30.9% 14.1% 5.5%
7 The course aims to get the best out of the residents.
18.9% 44.3% 26.3% 7.4% 3.1%
8 Our supervisors are motivated to attend. 26.1% 36.6% 25.1% 7.9% 4.3%
9 The feedback is considered and may lead to changes.
22.2% 32.3% 28.2% 11.7% 5.5%
10 After this HDRC session, I am motivated to attend the next one.
19.9% 35.6% 30.1% 8.9% 5.5%
Table 2: Attitudes of family medicine residents toward the HDRC (n = 418). Data presented are
%.
# Statements Total
1 Did you attend the previous four sessions? 90.4%
2 Did you provide a feedback for all four sessions? 30.6%
3 Have you presented any topic in the past three months? 89.2%
4 Have you asked any questions to clarify your doubts in any of the last four sessions?
73.2%
5 Do you attend the HDRC ONLY to mark your attendance and acquire scores for continuous assessment?
35.2%
6 Do you counsel other aspirant residents to opt for the family medicine residency course?
75.9%
7 Have you helped other residents in preparing the HDRC in any of the previous four sessions?
55.7%
8 Have you consulted any faculty in the preparation of your last three presentations?
56.5%
9 Have you ever intentionally missed the HDRC, in which you were the speaker during the last three months?
11.7%
10 Have you ever intentionally missed the HDRC, in which you were an attendee during the last three months?
19.6%
Table 3: Correlation between perception domains and attitude scores (n = 418). Data presented are Pearson's correlation r and p values.
Variable Positive Attitude Negative attitude
Motivation score Pearson correlation 0.426 −0.246
P value <0.001 <0.001
Perceived benefit score
Pearson correlation 0.39 −0.25
P value <0.001 <0.001
Quality of the course Pearson correlation 0.28 −0.065
P value <0.001 0.19
To understand the gender distribution across the five domains perception and attitude, we applied Mann-Whitney U test. Apart from the quality of the course and negative attitude, a significant difference was observed between the male
and female mean scores. We applied Kruskal Wallis H test to determine the difference between the mean scores across the five domains toward HDRC.
Table 4 presents the mean ± SD.
Table 4: Gender and residency-level distributions (mean ± SD) of perception and attitudes toward the HDRC (n = 418). Data presented are mean ± SD and p value for Mann-Whitney U and Kruskal Wallis H tests.
Variable n Motivation Perceived benefit
Quality Positive attitude
Negative attitude Gender Male 200 3.8 ± .8* 4.0 ± .7* 3.6 ± .9 3.6 ± .9* 1.0 ± 1.5 Female 218 3.5 ± .9* 3.8 ± .8* 3.6 ± .8 3.3 ± 1.0* 1.2 ± 1.4 Residency
level
R1 145 3.8 ± .7# 4.0 ± .6# 3.7 ± .7# 3.5 ± 1.0# .9 ± 1.4 R2 125 3.7 ± .8# 3.9 ± .7# 3.6 ± .8# 3.5 ± 1.0# 1.2 ± 1.5 R3 101 3.3 ± 1.0# 3.7 ± .8# 3.3 ± 1.0# 3.2 ± .8# 1.3 ± 1.3 R4 47 3.7 ± 1.0# 4.0 ± .8# 3.7 ± .9# 3.7 ± 1.0# 1.1 ± 1.6
* = Statistically significant difference between the male and female median scores (p <0.05) obtained using the Mann -Whitney U test. # = Statistically significant difference between the median scores based on residency years (p <0.05) obtained using the Kruskal Wallis H test.
Discussion
HDRC is a mandatory weekly activity conducted at the focal center, which is attended by the residents of all levels. The topics covered in these sessions range from the leadership and management in family medicine practices to advancement in pharmacological treatments of complex diseases(11). In general, the residents present the topic using an interactive approach under supervision(12,14). The attending physicians and residents ask questions, provide feedback, and rate the content and presenter. Furthermore, the course constitutes for 20% marks in the annual assessment of residents. In this study, we observed that overall motivation was fair among the participants, presenters, and supervisors because approximately 33% and 55%
participants were enthusiastic to attend HDRC and intended to attend the next session, respectively. Further, 50%
participants believed that their colleagues were motivated to attend, and approximately 66% participants considered that their supervisors were motivated to attend HDRC. The results were consistent with those of the other studies published for different specialties(4,12).
Motivated participants invigorate the program, and the end users enjoy the
program. If the primary beneficiaries are interested in the course, the aim of self- directed learning can be easily achieved(2,13,14). Similar to other disciplines of medicine, family medicine is a continuously advancing field that requires continuous update. Because the residents are involved in practice and are motivated to update their skills and knowledge, we can conclude that HDRC is achieving one of its goals. In this study, on a scale of 0 to 5, the mean motivation score was 4, which was fairly high. The results were consistent with the other reports(4,5).
For a resident to be promoted to the following year, 75% attendance is mandatory. We found that 90% of the respondents attended all of the previous four sessions. On a scale of 0 to 5, the mean positive attitude and mean negative scores were 3.5 and 1.1, respectively.
Both the scores are acceptable considering in the view diversity of residency programs in different regions across Saudi Arabia. The results were similar to those reported in a study by Babenko et al(1). Only 30% and 35%
participants provided the feedback and attended the session only to mark their attendance, respectively. From the available data, we cannot conclude the reasons of not providing feedback or of attending sessions only to mark the
presence. Furthermore, 82% participants conveyed that the topics presented are relevant, whereas 62% participants considered that HDRC gets the best out of the residents. A study evaluated the educational environment in the family medicine residency program and concluded that the program structure requires considerable changes(15). However, in this study, the mean perceived benefit and mean quality scores were 4, which can be considered fair and acceptable. Similarly, in the previous study, for understanding the level of satisfaction with the diploma in family medicine, residents were satisfied with the quality of the program(16).
The correlation between the motivation score and positive attitude was moderate and positive (r = 0.426, p <0.001).
Moreover, the correlation coefficient between the benefit score and positive attitude was moderate. No correlation was observed between the negative attitude and the quality of the program (r =
−0.065, p = 0.19). In the previous studies, the quality of the course and availability of the resources were satisfactory(12,16). The cross-tabulation between the mean scores of the five domains of perception and attitude in terms of the residency level and gender revealed that the third- year residents were different from those in the other three levels (p <0.05 - Kruskal Wallis H test). The curriculum and assessment methods may be particularly different for the third year. Similarly, in all domains, female residents had lower scores than male residents.
Conclusion
HDRC achieved its goal of motivating the residents for self-directed learning. The total registered residents in the family medicine residency program were approximately 1760, and the data was collected from 418 residents (23.75%) across all regions of Saudi Arabia, including central, western, eastern, southern, and northern regions, and from different sponsors, such as the Ministry of Health, Ministry of National Guards, and universities. The overall perception and attitude of residents toward HDRC are satisfactory. We found that 72%
participants were enthusiastic to attend
the HDRC and 55% expressed enthusiasm to attend future sessions. The constructive consideration of the feedback may improve the course. The inclusion of the residents when selecting the topics of presentation, mode of delivery, and presentation technique can improve HDRC. The residents who attend only to mark attendance (35%) can benefit by an innovative learning and teaching methodology. The strengths of the study include a suitable sample size and representative sampling.
Limitations of the Study
The current study is non-probability convenience sampling, the lack of data comparison with local and international programs, and the lack of a qualitative component are some of the study limitations. A qualitative component to understand the reasons of differences between the scores of the third-year and other residents is required. The results are needed be validated using 360-degree feedback from the other two stakeholders, namely program directors and supervisors. The available research on this subject for different local and international programs is not sufficient, and thus, we were unable to compare and contrast our results.
Funding
This study was funded by the respective authors' institutions as part of their employment duties and was conducted as a requirement for residency training (Saudi Board of Family Medicine).
Conflict of Interests
The authors declared no conflict of interests.
Acknowledgement
We want to thank all residents who participated in the research.
References
1. Babenko O, Szafran O, Koppula S, Au L.
Motivations for learning of family medicine residents trained in competency- based education. Educ Prim Care, 2018;29(2):86-93.
2. Sawatsky AP, Ratelle JT, Bonnes SL, Egginton JS, Beckman TJ. A model of self-directed learning in internal medicine residency: a qualitative study using
grounded theory. BMC Med Educ., 2017;17(1):31.
3. Morgan R, Kauffman DF, Doherty G, Sachs T. Resident and Attending Perceptions of Resident Involvement: An Analysis of ACGME Reporting Guidelines. J Surg Educ. 2017;74(3):415- 22.
4. Eid A, Hsieh P, Shah P, Wolff R. Cross- sectional longitudinal study of the academic half-day format in a hematology- oncology fellowship training program.
BMC Medical Education, 2015;15(1):139.
5. Lafraia FM, Herbella FAM, Kalluf JR, Schlottmann F, Patti MG. Attitudes and experiences during training and professional expectations in generation-y surgical residents. Rev Assoc Med Bras.
(1992), 2019;65(3):348-54.
6. Andijany MA, AlAteeq MA. Family medicine residents in central Saudi Arabia.
How much do they know and how confident are they in performing minor surgical procedures? Saudi Med J., 2019;40(2):168-76.
7. Dotters-Katz S, Hargett CW, Zaas AK, Criscione-Schreiber LG. What motivates residents to teach? The Attitudes in Clinical Teaching study. Med Educ., 2016;50(7):768-77.
8. Al-Khaldi YM, Al-Ghamdi EA, Al- Mogbil TI, Al-Khashan HI. Family medicine practice in Saudi Arabia: The current situation and Proposed Strategic Directions Plan 2020. J Family Community Med., 2017;24(3):156-63.
9. Birrer R, Al-Enazy H, Sarru E. Family medicine in Saudi Arabia-next steps.
Journal of Community Medicine & Health Education S., 2014;2:2161-0711.
10. Osman H, Romani M, Hlais S. Family medicine in Arab countries. Family Medicine, 2011;43(1):37.
11. Al-Khaldi YM, AlDawood KM, AlBar AA, Al-Shmmari SA, Al-Ateeq MA, Al- Meqbel TI, et al. Challenges facing postgraduate training in family medicine in Saudi Arabia: Patterns and solutions.
Journal of Health Specialties, 2014;2(2):61.
12. Alsharif T, Hussein S. Assessment of family medicine residents? Satisfaction regarding the half day release course of family medicine program. International Journal of Advanced Research, 2017;5(9):264-71.
13. AlShareef MH. Satisfaction of family physicians during their training program, Jeddah, Saudi Arabia. International
Journal of Medical Science and Public Health, 2014;3(6):649-60.
14. Raetz J, Unwin B, Andrilla HA. Attitudes and Barriers Encountered in Training Family Medicine Residents in Nursing Home Care: A National Survey of Program Directors: A CERA Study. Fam Med., 2016;48(4):309-13.
15. Khoja AT. Evaluation of the educational environment of the Saudi family medicine residency training program. Journal of Family & Community Medicine, 2015;22(1):49-56.
1. Al-Khaldi YM, AlDawood KM, AlKhudeer BK, AlSaqqaf AA. Satisfaction of trainees of Saudi Diploma Family Medicine, Saudi Arabia. Educ Prim Care, 2016;27(5):421-3.
