Postgraduate Medical Education Programs Research Articles

Educating vocationally trained family physicians: a survey of graduates from a postgraduate medical education programme

INTRODUCTION Since 1991 the University of Otago, Dunedin, New Zealand has offered postgraduate qualifications specifically designed to educate general practitioners (GPs) about their unique work environment. AIM To determine motivations and impacts of postgraduate education for practising GPs. METHODS Survey of the 100 graduates of the University of Otago, Dunedin postgraduate general practice programme. Ninety five living graduates were approached and 70 (73.7%) responded. Quantitative data about disposition of respondents before enrolling and after completion of the programme were analysed using chi-square and paired t-tests. Free text responses about motivations, impacts and outcomes of the program were thematically analysed. RESULTS 64 GPs graduated with a postgraduate diploma and 36 with a masters degree in general practice. Although the mean number of graduates was 3.5 and 2.0 (respectively), annual enrolments averaged 25.1. Most graduates (60.9%) were aged in their 40s when they started studying and most (94.3%) had a spouse and/or children at home. DISCUSSION This voluntary postgraduate medical education complements traditional medical training but has low external value despite personal, practising and professional benefits. Graduates valued engagement above completion of a qualification. KEYWORDS Medical education; general practitioners; scholarship; professionalism.

Identifying and Promoting Best Practices in Residency Application and Selection in a Complex Academic Health Network.

Medical education institutions have a social mandate to produce a diverse physician workforce that meets the public's needs. Recent reports have framed the admission process outcome of undergraduate and postgraduate medical education (UGME and PGME) programs as a key determinant of the collective contributions graduating cohorts will make to society, creating a sense of urgency around the issue of who gets accepted. The need for evidence-informed residency application and selection processes is growing because of the increasing size and diversity of the applicant pool and the need for equity, fairness, social accountability, and health human resource planning. The selection literature, however, is dominated by a UGME focus and emphasizes determination of desirable qualities of future physicians and selection instrument reliability and validity. Gaps remain regarding PGME selection, particularly the creation of specialty-specific selection criteria, suitable outcome measures, and reliable selection systems.In this Perspective, the authors describe the University of Toronto's centralized approach to defining system-level best practices for residency application and selection. Over the 2012-2013 academic year, the Best Practices in Application and Selection working group reviewed relevant literature and reports, consulted content experts, surveyed local practices, and conducted iterative stakeholder consultations on draft recommendations. Strong agreement arose around the resulting 13 principles and 24 best practices, which had either empirical support or face validity. These recommendations, which are shared in this article, have been adopted by the university's PGME advisory committee and will inform a national initiative to improve trainees' transition from UGME to PGME in Canada.

Population aging and physician maldistribution: A longitudinal study in Japan

Background: Over the past two decades, population aging and the introduction of the new postgraduate medical education program in 2004 have impacted on the geographic maldistribution of physicians in Japan. The purpose of this study was to evaluate recent changes in physician distribution across municipalities from 1996 to 2012 using Gini coefficients and to clarify the impact of the new medical education program on physician distribution.Methods: We extracted the number of physicians classified by type of medical institution and municipal bodies. Gini coefficients were calculated using both population and demand for medical services. We calculated the contribution ratio (CR) of maldistribution within each type of medical institution to the whole maldistribution using Rao’s method. In addition, we calculated the incremental difference in Gini coefficients between 2002 and 2010, and calculated the CR of the incremental Gini coefficient difference for each medical institution type using Seki’s method.Results: Both Gini coefficients decreased from 1996 to 2002, and increased after 2006. The CR of other hospitals increased from 2004. The incremental difference in the Gini coefficient using demand between 2002 and 2010 was 0.012, and the CR of each type of medical institution was -25.1% (university hospitals), 131.0% (other hospitals) and -5.9% (clinics).Conclusions: Our analysis showed that the geographic maldistribution of physicians has worsened since the introduction of the new postgraduate medical education program, and the CR of maldistribution in other hospitals was high. Our study suggested that new medical resource distribution policies should be discussed to improve maldistribution.

How do postgraduate qualifications in medical education impact on health professionals?

Background and Purpose: The number of degree-awarding programmes in medical education is steadily increasing. Despite the popularity and extensive investment in these courses, there is little research into their impact. This study investigated the perceived impact of an internationally-renowned postgraduate programme in medical education on health professionals’ development as educators.Methods: An online survey of the 2008–12 graduates from the Centre for Medical Education, University of Dundee was carried out. Their self-reported shifts in various educational competencies and scholarship activities were analysed using non-parametric statistics. Qualitative data were also collected and analysed to add depth to the quantitative findings.Results: Of the 504 graduates who received the online questionnaire 224 responded. Participants reported that a qualification in medical education had significantly (p < 0.001) improved their professional educational practices and engagement in scholarly activities. Masters graduates reported greater impact compared to Certificate graduates on all items, including ability to facilitate curriculum reforms, and in assessment and feedback practices. Masters graduates also reported more engagement in scholarship activities, with significantly greater contributions to journals. These qualifications equally benefited all participants regardless of age. International graduates reported greater impact of the qualification than their UK counterparts.Conclusion: A postgraduate medical education programme can significantly impact on the practices and behaviours of health professionals in education, improving self-efficacy and instilling an increased sense of belonging to the educational community.

Preparedness for practice: A systematic cross-specialty evaluation of the alignment between postgraduate medical education and independent practice

Background: Postgraduate medical education training programs strive to prepare their trainees optimally for independent practice. Several studies have shown, however, that new consultants feel inadequately prepared for practice, and that this increases the risk of stress and burnout.Aim: To analyze across specialties for which tasks and themes new consultants feel inadequately prepared. And, to identify themes that need improved attention in postgraduate medical education programs or after registration.Methods: 330 New consultants from all hospital specialities with accredited training programs who completed their training in the north-eastern educational region of The Netherlands between 2004 and 2010 received a questionnaire which was based on a previously validated generic task inventory.Results: 143 respondents (43%) returned the questionnaire. They felt excellently prepared for 40 tasks, well prepared for 25 tasks, marginally sufficiently prepared for 18 tasks and insufficiently prepared for 8 tasks. Preparedness scores were lowest for tasks concerning management administration and leadership, research, end-of-life care, and patient safety-related communication. Surgical specialists felt better prepared for practice than medical specialists, which could not be explained by differences in general self-efficacy.Conclusion: Although new consultants felt well prepared for medical tasks, the scores of more generic tasks indicate that the alignment between the different phases of the medical education continuum and independent practice needs improvement.

Clinical audit in the final year of undergraduate medical education: Towards better care of future generations

Background: In Australia, in an environment undergoing rapidly changing requirements for health services, there is an urgent need for future practitioners to be knowledgeable, skilful and self-motivated in ensuring the quality and safety of their practice. Postgraduate medical education and vocational programs have responded by incorporating training in quality improvement into continuing professional development requirements, but undergraduate medical education has been slower to respond.Aims: This article describes the clinical audit programme undertaken by all students in the final year of the medical course at the University of Notre Dame, Fremantle, Australia, and examines the educational worth of this approach.Methods: Data were obtained from curricular documents, including the clinical audit handbook, and from evaluation questionnaires administered to students and supervisors.Results: The clinical audit programme is based on sound educational principles, including situated and participatory learning and reflective practice. It has demonstrated multi-dimensional benefits for students in terms of learning the complexities of conducting an effective audit in professional practice, and for health services in terms of facilitating quality improvement.Conclusion: Although this programme was developed in a medical course, the concept is readily transferable to a variety of other health professional curricula in which students undertake clinical placements.

A survey of Sub-Saharan African medical schools

BackgroundSub-Saharan Africa suffers a disproportionate share of the world's burden of disease while having some of the world's greatest health care workforce shortages. Doctors are an important component of any high functioning health care system. However, efforts to strengthen the doctor workforce in the region have been limited by a small number of medical schools with limited enrolments, international migration of graduates, poor geographic distribution of doctors, and insufficient data on medical schools. The goal of the Sub-Saharan African Medical Schools Study (SAMSS) is to increase the level of understanding and expand the baseline data on medical schools in the region.MethodsThe SAMSS survey is a descriptive survey study of Sub-Saharan African medical schools. The survey instrument included quantitative and qualitative questions focused on institutional characteristics, student profiles, curricula, post-graduate medical education, teaching staff, resources, barriers to capacity expansion, educational innovations, and external relationships with government and non-governmental organizations. Surveys were sent via e-mail to medical school deans or officials designated by the dean. Analysis is both descriptive and multivariable.ResultsSurveys were distributed to 146 medical schools in 40 of 48 Sub-Saharan African countries. One hundred and five responses were received (72% response rate). An additional 23 schools were identified after the close of the survey period. Fifty-eight respondents have been founded since 1990, including 22 private schools. Enrolments for medical schools range from 2 to 1800 and graduates range from 4 to 384. Seventy-three percent of respondents (n = 64) increased first year enrolments in the past five years. On average, 26% of respondents' graduates were reported to migrate out of the country within five years of graduation (n = 68). The most significant reported barriers to increasing the number of graduates, and improving quality, related to infrastructure and faculty limitations, respectively. Significant correlations were seen between schools implementing increased faculty salaries and bonuses, and lower percentage loss of faculty over the previous five years (P = 0.018); strengthened institutional research tools (P = 0.00015) and funded faculty research time (P = 0.045) and greater faculty involvement in research; and country compulsory service requirements (P = 0.039), a moderate number (1-5) of post-graduate medical education programs (P = 0.016) and francophone schools (P = 0.016) and greater rural general practice after graduation.ConclusionsThe results of the SAMSS survey increases the level of data and understanding of medical schools in Sub-Saharan Africa. This data serves as a baseline for future research, policies and investment in the health care workforce in the region which will be necessary for improving health.

Current Approaches to Journal Club by General Surgery Programs Within the Southwestern Surgical Congress

Journal club (JC) is a well-recognized education tool for many postgraduate medical education programs. Journal club helps residents learn critical analytic skills and keep up to date with current medical practices. To our knowledge, there is minimal evidence in the current literature detailing modern JC practices of general surgery training programs. Our study attempts to define how general surgery residency programs are implementing JC in their training process. We distributed by mail a 14-question survey to general surgery program directors within the Southwestern Surgical Congress. These surveys were redistributed 1 month after the initial attempt. The responses were collected and analyzed. Survey questions aimed to define JC practice characteristics, such as where JC is held, when JC is held, who directs JC, what journals are used, the perceived importance of JC, and average attendance. The surveys were sent to 32 program directors (PDs), which included 26 university and 6 community-based programs. We received responses from 26 (81%) PDs. Ninety-two percent of the programs have a consistent journal club (JC). Most JCs meet monthly (64%) or weekly (16%). The meeting places ranged from conference rooms (60%), faculty homes (20%), restaurants (8%), or in the hospital (12%). The meeting times were divided between morning (29%), midday (29%), and evening (42%). Most JCs lasted between 1 and 2 hours (88%), reviewed 1-4 articles (88%), and are attended by more than 60% of residents routinely (75%). Half of the programs (50%) had 3-4 faculty members present during discussion; 29% of the programs had only 1-2 faculty present. The articles were selected from more than 10 different journals. Seventy-five percent of the programs used the American Journal of Surgery and Annals of Surgery to find articles; only 13% of the programs used evidence-based reviews in surgery. PDs believe JC is very beneficial (42%), moderately beneficial (42%), or only fairly beneficial (16%). According to PDs, JC is most beneficial because it improves clinical knowledge (88%), initiates additional reading (62%), and improves American Board of Surgery In-Training Examination (ABSITE) scores (15%). Journal club has historically been an integral part of general surgery training. Our research indicates that journal club is still used widely as a beneficial educational resource and helps meet core competency requirements.

American Diagnostic Radiology Residency and Fellowship Programmes

American Diagnostic Radiology Residency and Fellowship programmes are Graduate Medical Education programmes in the United States (US) equivalent to the Postgraduate Medical Education programmes in Singapore. Accreditation Council for Graduate Medical Education (ACGME) accredited diagnostic radiology residency programmes require 5 years total with Post Graduate Year (PGY) 1 year internship in a clinical specialty, e.g. Internal Medicine following medical school. PGY Years 2 to 5 are the core years which must include Radiology Physics, Radiation Biology and rotations in 9 required subspecialty rotations: Abdominal, Breast, Cardiothoracic, Musculoskeletal, Neuroradiology, Nuclear and Paediatric Radiology, Obstetric & Vascular Ultrasound and Vascular Interventional Radiology. A core curriculum of lectures must be organised by the required 9 core subspecialty faculty. All residents (PGY 2 to 4) take a yearly American College of Radiology Diagnostic In-Training Examination based on national benchmarks of medical knowledge in each subspecialty. Because the American Board of Radiology (ABR) examinations are changing, until 2012, residents have to take 3 ABR examinations: (i) ABR physics examination in the PGY 2 to 3 years, (ii) a written examination at the start of the PGY 5 year and (iii) an oral exam at the end of the PGY 5 year. Beginning in 2013, there will be only 2 examinations: (i) the physics and written examinations after PGY 4 will become a combined core radiology examination. Beginning in 2015, the final certifying examination will be given 15 months after the completion of residency. After residency, ACGME fellowships in PGY 6 are all one-year optional programmes which focus on only one subspecialty discipline. There are 4 ACGME accredited fellowships which have a Board Certifi cation Examination: Neuroradiology, Nuclear, Paediatric and Vascular Interventional Radiology. Some ACGME fellowships do not have a certifying examination: Abdominal, Endovascular Surgical Neuroradiology and Musculoskeletal Radiology. One year unaccredited fellowships can also be taken in Breast, Cardiothoracic or Women's Imaging.

The New Japanese Postgraduate Medical Education and Quality of Emergency Medical Care

BackgroundThe new postgraduate medical education (PGME) was recently introduced to improve quality of emergency care in Japan. ObjectivesTo compare the quality of care and confidence in provision of emergency medicine between physicians who completed the old and new PGME programs. MethodsA cross-sectional survey was sent to 279 physicians of postgraduate years 4–9, and 208 responses (75%) were received. Quality of care in emergency medicine was measured using 26 questions on treatment choices for various clinical conditions. Each question had six responses, including a single correct choice. Effect size was obtained by dividing the total difference in score by the standard deviation of the score distribution. Confidence in emergency medicine was rated using four self-reported items on the level of confidence in treating acute illnesses in various emergency medicine settings. ResultsThe mean score for quality of care was significantly higher in the new PGME group (15.3) compared to the old PGME group (12.8). The difference in scores was 2.5 (p < 0.01) and the effect size (0.47) indicated a moderate difference. Linear regression of total scores adjusted for physician covariates produced similar results of an adjusted score difference of 2.5 (p < 0.01) and an adjusted effect size of 0.47. The new PGME group also had significantly greater confidence in provision of emergency medicine based on significant differences between the groups for all four self-reported items (all p < 0.05). ConclusionsJapanese physicians who complete the new PGME program are likely to provide higher quality of care and have greater confidence in emergency medicine compared to those who completed the old PGME program.

Participating in a Community of Learners enhances resident perceptions of learning in an e-mentoring program: proof of concept

BackgroundCommunity learning and e-mentoring, learning methods used in higher education, are not used to any extent in residency education. Yet both have the potential to enhance resident learning and, in the case of community learning, introduce residents to basic lifelong learning skills. We set out to determine whether residents participating in an Internet based e-mentoring program would, with appropriate facilitation, form a community of learners (CoL) and hold regular community meetings. We also determined resident and faculty perceptions of CoL and Internet sessions as effective learning experiences.MethodsA six-month e-mentoring pilot was offered to 10 Radiology residents in the Aga Khan University Postgraduate Medical Education Program in Nairobi, Kenya (AKUHN) with a Professor of Radiology, located at University of Virginia, USA, acting as the e-mentor. Monthly Internet case-based teaching sessions were facilitated by the e-mentor. In addition, residents were coached by a community facilitator to form CoL and collectively work through clinical cases at weekly face-to-face CoL sessions.Event logs described observed resident activity at CoL sessions; exit survey and interviews were used to elicit perceptions of CoL and Internet sessions as effective learning experiences.ResultsResident adoption of CoL behaviors was observed, including self-regulation, peer mentoring and collaborative problem solving. Analysis revealed high resident enthusiasm and value for CoL. Surveys and interviews indicated high levels of acceptance of Internet learning experiences, although there was room for improvement in audio-visual transmission technologies. Faculty indicated there was a need for a larger multi-specialty study.ConclusionsThe pilot demonstrated resident acceptance of community building and collaborative learning as valued learning experiences, addressing one barrier to its formal adoption in residency education curricula. It also highlighted the potential of e-mentoring as a means of expanding faculty and teaching materials in residency programs in developing countries.

Northern Ontario School of Medicine

Northern Ontario School of Medicine

Surgery in the Horn of Africa

To describe the 1-year experience of a unique postgraduate medical education program set in Eritrea, a recently war-torn country. The Partnership for Eritrea, a cooperative between The George Washington University Medical Center, Physicians for Peace, and the Eritrean Ministry of Health, formed a surgical residency program, launched January 2, 2008, in Asmara, Eritrea, to train native Eritrean surgeons. No prior residency program (to our knowledge) had existed in Eritrea. Eritrea, a country in the Horn of Africa. Five Eritrean physicians participated in the surgical residency. The number of operations performed, length of stay, antibiotic use, and intravenous fluid use. The number of operations increased and resource use decreased because of improved and standardized clinical management. The Partnership for Eritrea established a general surgical residency program that improved clinical care in a resource-poor country that previously had lacked postgraduate training. The program experience suggests a model that can be reproduced in other developing countries.

Learning in a Virtual World: Experience With Using Second Life for Medical Education

BackgroundVirtual worlds are rapidly becoming part of the educational technology landscape. Second Life (SL) is one of the best known of these environments. Although the potential of SL has been noted for health professions education, a search of the world’s literature and of the World Wide Web revealed a limited number of formal applications of SL for this purpose and minimal evaluation of educational outcomes. Similarly, the use of virtual worlds for continuing health professional development appears to be largely unreported.MethodsWe designed and delivered a pilot postgraduate medical education program in the virtual world, Second Life. Our objectives were to: (1) explore the potential of a virtual world for delivering continuing medical education (CME) designed for physicians; (2) determine possible instructional designs using SL for CME; (3) understand the limitations of SL for CME; (4) understand the barriers, solutions, and costs associated with using SL, including required training; and (5) measure participant learning outcomes and feedback. We trained and enrolled 14 primary care physicians in an hour-long, highly interactive event in SL on the topic of type 2 diabetes. Participants completed surveys to measure change in confidence and performance on test cases to assess learning. The post survey also assessed participants’ attitudes toward the virtual learning environment.ResultsOf the 14 participant physicians, 12 rated the course experience, 10 completed the pre and post confidence surveys, and 10 completed both the pre and post case studies. On a seven-point Likert scale (1, strongly disagree to 7, strongly agree), participants’ mean reported confidence increased from pre to post SL event with respect to: selecting insulin for patients with type 2 diabetes (pre = 4.9 to post = 6.5, P= .002); initiating insulin (pre = 5.0 to post = 6.2, P= .02); and adjusting insulin dosing (pre = 5.2 to post = 6.2, P= .02). On test cases, the percent of participants providing a correct insulin initiation plan increased from 60% (6 of 10) pre to 90% (9 of 10) post (P= .2), and the percent of participants providing correct initiation of mealtime insulin increased from 40% (4 of 10) pre to 80% (8 of 10) post (P= .09). All participants (12 of 12) agreed that this experience in SL was an effective method of medical education, that the virtual world approach to CME was superior to other methods of online CME, that they would enroll in another such event in SL, and that they would recommend that their colleagues participate in an SL CME course. Only 17% (2 of 12) disagreed with the statement that this potential Second Life method of CME is superior to face-to-face CME.ConclusionsThe results of this pilot suggest that virtual worlds offer the potential of a new medical education pedagogy to enhance learning outcomes beyond that provided by more traditional online or face-to-face postgraduate professional development activities. Obvious potential exists for application of these methods at the medical school and residency levels as well.

The Virtual Practice: Using the Residents' Continuity Clinic to Teach Practice Management and Systems-Based Practice

Education in systems-based practice is a required component of all postgraduate medical education programs in the United States. Competency in this area requires that trainees have an understanding of the health care system sufficient to provide optimal care to patients. Most trainees in residency programs have little understanding of the complexities and challenges of present-day practice in the current system of care and consider themselves unprepared to undertake this activity following completion of training. Training in practice management in residency programs has not been emphasized as an important component of systems-based practice. Historically, practice management training in residency programs has been done using a fully didactic model, and residents have expressed a desire to learn this skill by becoming more directly involved in the operations and management of a practice. The patient visit touches many aspects of the health care system, including clinic operations, insurance, quality, and finances. At our institution, we used the residents' continuity clinic practices as a vehicle to provide education in practice management and systems-based practice by creating a curriculum that included the residents' perceived gaps in knowledge regarding going into practice. This is known as the virtual practice. This curriculum is taught using data obtained from residents' practice to illustrate concepts in many areas, including primary practice operations, malpractice insurance, financial benchmarks, and career planning. Resident self-assessed knowledge of these areas increased after participating in the curriculum, and resident testimonials indicate satisfaction with the project. In addition, residents have become engaged and interested in how their effort translates into performance and how they participate in the health care system.

Trauma care - a participant observer study of trauma centers at Delhi, Lucknow and Mumbai.

Trained doctors and para-medical personnel in accident and emergency services are scant in India. Teaching and training in trauma and emergency medical system (EMS) as a specialty accredited by the Medical Council of India is yet to be started as a postgraduate medical education program. The MI and CMO (casualty medical officer) rooms at military and civilian hospitals in India that practice triage, first-aid, medico-legal formalities, reference and organize transport to respective departments leads to undue delays and lack multidisciplinary approach. Comprehensive trauma and emergency infrastructure were created only at a few cities and none in the rural areas of India in last few years. To study the infrastructure, human resource allocation, working, future plans and vision of the established trauma centers at the 3 capital cities of India - Delhi (2 centres), Lucknow and Mumbai. Participant observer structured open ended qualitative research by 7 days direct observation of the facilities and working of above trauma centers. Information on, 1. Infrastructure; space and building, operating, ventilator, and diagnostic and blood bank facilities, finance and costs and pre-hospital care infrastructure, 2. Human resource; consultant and resident doctors, para-medical staff and specialists and 3. Work style; first responder, type of patients undertaken, burn management, surgical management and referral system, follow up patient management, social support, bereavement and postmortem services were recorded on a pre-structured open ended instrument interviewing the officials, staff and by direct observation. Data were compressed, peer-analyzed as for qualitative research and presented in explicit tables. Union and state governments of Delhi, Maharashtra and Uttar Pradesh have spent heavily to create trauma and emergency infrastructure in their capital cities. Mostly general and orthopedics surgeons with their resident staff were managing the facilities. Comprehensively trained accident and emergency (AandE) personnel were not available at any of the centers. Expert management of cardiac peri-arrest arrhythmias, peripheral and microvascular repair were occasionally available. Maxillo-facial, dental and prosthodontic facilities, evenomation grading and treatment of poisoning - anti venom were not integrated. Ventilators, anesthetist, neuro and plastic surgeons were available on call for emergency care at all the 4 centers. Emergency diagnostic radiology (X-ray, CT scan, and ultrasound) and pathology were available at all the 4 centers. On the spot blood bank and component blood therapy was available only at the Delhi centers. Pre-hospital care, though envisioned by the officials, was lacking. Comprehensively trained senior A and E personnel as first responders were unavailable. Double barrier nursing for burn victims was not witnessed. Laparoscopic and fibreoptic endoscopic emergency procedures were also available only at Delhi. Delay in treatment on account of incomplete medico-legal formalities was not seen. Social and legal assistance, bereavement service and cold room for dead body were universally absent. Free treatment at Delhi and partial financial support at Lucknow were available for poor and destitute. Though a late start, evolution of trauma services was observed and huge infrastructure for trauma have come up at Delhi and Lucknow. Postgraduate accreditation in Trauma and EMS and creation of National Injury Control Program must be mandated to improve trauma care in India. Integration of medical, non traumatic surgical and pediatric emergency along with pre-hospital care is recommended.

Regulation of the Postgraduate Medical Education

In this paper we analyse three aspects of the postgraduate medical education programmes – financing, quality assurance, and workforce planning – and investigate whether these activities should be regulated by the government or left to market forces. To answer this question we rely on the framework offered by different regulation theories. The approaches of the public interest, contract, capture and enforcement theory have all been used. From our analysis it appears that the enforcement theory offers the best means to deal with this market. Our findings show that governmental intervention is desirable in the financing of postgraduate medical education; to guarantee qualitatively good educational programmes both regulation and enforced self-regulation can be used according to the specific situation of a country; and the planning of workforce via regulation is especially important in that group of professions, like specialists, exhibiting time lags. We further investigate the situation of the postgraduate medical education programme in two countries, Belgium and England, to understand how the issues of financing, quality assurance, and workforce planning in these two different set-ups have been tackled.

No Relief in Sight: Postgraduate Training in Pain Management

This study investigated training in pain management in postgraduate medical education programs. A mail survey of program directors was conducted, evaluating the format of training in pain management and the self-assessed adequacy of the training. The response rate was 70%, with 188 total respondents. It included all programs in a large Midwestern state, representing most specialties. Just over half of all programs offered any formal training in pain management, and even fewer required it. Less than one quarter required a clinical component to such training. Nonetheless, an overwhelming majority of program directors (85%) rated their training as adequate or excellent. Improvements are clearly needed in postgraduate training in pain management, and external incentives, such as requirements in the accreditation process, will be needed.

The Shift of Residents From University to Non-University Hospitals in Japan: A Survey Study

Between 2003 and 2004, when the new postgraduate medical education program was introduced in Japan, the number of university residents decreased from 5,923 to 3,264 (-31%), whereas the number of non-university residents increased from 2,243 to 4,110 (+45%). To identify potential reasons for the shift of residents from university to non-university hospitals. Cross-sectional mailed survey. The subjects were 1,794 2nd-year residents at 91 university hospitals and 2,010 2nd-year residents at 659 non-university hospitals. Data on hospital demographics, resident demographics, and resident satisfaction with training were collected in 2006 and were compared between university and non-university hospitals. Compared to non-university hospitals, university hospitals were more likely to have >700 beds (55% vs. 10%, p<0.001) and to have more teaching resources and free access to international medical journals (84% vs. 62%, p<0.001). Nevertheless, one-half (47%) of the university residents reported that they were not satisfied with the residency system and clinical skills training and attributed their dissatisfaction to "daily chores," "low salary," and "poor clinical opportunities." Logistic regression analyses indicated that the proportions of residents who were satisfied with income (OR: 0.32, 95% CI: 0.26-0.40) and the residency system (OR: 0.52, 95% CI: 0.40-0.68) and clinical skills training (OR: 0.77, 95% CI: 0.60-0.99) were significantly lower for university residents than for non-university residents. Hospital size and teaching resources do not overcome the other characteristics of university hospitals that lead to residents' dissatisfaction.

Improvement of residents' clinical competency after the introduction of new postgraduate medical education program in Japan

Background: In 2004, the Japanese government reformed the monospecialty-oriented postgraduate medical education (PGME) program and introduced a new PGME program to develop the primary care skills of physicians by mandatory rotation through different clinical departments.Aims: (1) to evaluate whether residents’ clinical competency improved after the introduction of the new PGME program and (2) to compare the change in competency between university and non-university residents.Method: Surveys were conducted before and after the introduction of the new PGME, i.e. in 2004 (response rate 88%) and 2006 (88%). One in every five residents was sampled, and the study subjects were 2474 second-year residents (1762 university residents and 712 non-university residents) in 2004 who were about to complete the previous PGME program and 1166 second-year residents (487 and 679) in 2006 who were the first generation to complete the new PGME program. The clinical competency ratings were measured by the proportion of respondents reporting ‘experience’ in 24 clinical specialties and three items regarding the use of medical records and ‘confidence’ in 35 clinical skills and knowledge items in four areas (i.e basic medicine, allied areas, behavioural science and social medicine, and clinical research).Results: Compared to the residents in 2004, the clinical experience and confidence level of the residents increased dramatically for almost all of the surveyed items in 2006, regardless of the type of teaching hospital (chi-square or Fisher's exact tests, P < 0.0001). The marked improvement in the clinical competency of university residents was noticeable, resulting in the disappearance of the historical trend for non-university residents to obtain significantly more clinical experience than university residents.Conclusions: The new PGME program appears to have been successful at improving both the clinical experience and confidence levels of medical residents, especially at university hospitals.