esidency programs are complex educational systems that provide residents with knowledge, attitudes, and skills required for the practice of their specialty (1). The task force on quality in residency training of the American Association of Directors of Psychiatric Residency Training (AADPRT) previously published a general definition of quality that applies to residency training: a customer centered framework. It is consistent with approaches to quality in health care and industry. This approach attempts to define and measure quality in terms of characteristics important to persons having a stake in the "business" (e.g., the residents, their future employers, their patients and the faculty where the program is offered) (2). An example of such an approach to quality is to identify the most important factors determining satisfaction with psychiatric training among residents. Competent residents are the backbone of a good training program and frequently go on to join the program’s faculty (3). Several reports have emphasized the influence of current resident satisfaction on the recruitment of future residents (4, 5).
Few studies have examined what factors determine residents’ satisfaction with psychiatric, or any other, specialty program. Skodol and Maxmen (6) surveyed 71 residents in four psychiatric training programs. They found that programs that increase residents’ perceived technical competence increase their satisfaction. Ratanawongsa et al. (7) found that resident well-being was closely related to professional development. Upper-level residents felt that as they progressed through their training, an increasing proportion of their work was satisfying because it contributed to their learning. In particular, residents appreciated faculty who offered feedback and support, indicating that faculty members valued the residents’ professional growth (7). Haupt et al. (8) surveyed 31 residents for factors contributing to satisfaction with their training program. The five most important factors related to resident satisfaction were: quality of teaching, feeling of (morale), trainee’s degree of responsibility for patient care, quality and number of conferences, and outpatient experience. Several studies found that the philosophy of the training program, especially the degree of eclecticism, was important to applicants as a criterion for selecting a training program (5, 9, 10). Surveys that have considered factors important to residency applicants in choosing a program have shown that the two most important factors are positive feelings about the program and degree of satisfaction of residents currently in the program (3—5). Several factors extrinsic to the quality of the training program also emerged, including geographic location and spousal satisfaction with the community (3—5, 9). Salary and working conditions were considered less important (4, 11).
In 1997, an AADPRT task force developed a questionnaire to define the variables important to determining a psychiatric program’s quality from the residents’ perspective. The 41-item instrument was based on focus groups of residents and program directors, as well as on a review of the literature. The questionnaire was submitted to 38 programs. One hundred eighty residents from 16 programs completed the survey. The residents were asked to indicate on a five-point Likert scale the importance attached to each factor in determining their satisfaction with the residency training (1=not important in determining the quality of a residency training program, 5=very important in determining the quality of a residency training program). The 10 items most important to residents’ satisfaction were: quality of supervision, quality of teaching conferences, respect of faculty for residents, responsiveness of program to feedback from residents, amount of responsibility for patient care delegated to residents, education prioritized over service, training in biomedical psychiatry, training in psychosocial aspects of psychiatry, morale in department, and level of support from peers. The task force then constructed the Resident Satisfaction Questionnaire based on these items. Training directors can now use this Questionnaire to measure current residents’ satisfaction with each of these items, and thus compare satisfaction data over time and across programs. A detailed description of the survey and of the construction of the Resident Satisfaction Questionnaire was published by Elliott et al. (10).
We set out to gain a better understanding of the factors important for Israeli psychiatric residents in determining their satisfaction with residency training and to compare the results with the U.S findings. We aimed to compose a list of the most important factors that would assist program directors to improve training programs.
We used the instrument developed by Elliott et al. (10), with a minor modification (Table 1
). We omitted the item "progression in level of responsibility" because of the overlap in content with the item "amount of responsibility for patient care delegated to residents," and the latter item had the greater test-retest reliability. The instrument did not include factors extrinsic to training programs (e.g., geographical location) to use the same methodology used by Elliott et al. (10). Although some believe such factors are of great importance to residency applicants, most of the factors are not under the control of the training program director and would be of lesser value in helping directors to improve residents’ satisfaction.
We distributed the questionnaire to psychiatric residents in Israel by e-mail during February and March, 2006. All members who did not respond to the e-mail message within 2 weeks were e-mailed a follow-up survey package. We also distributed the questionnaire at several residents’ conferences. We clarified to the residents that the purpose of the survey was not to determine their current satisfaction with residency training. They were asked to rate the importance of each factor in determining their satisfaction with residency training (with 5 indicating the highest importance). We also recorded demographic information and program descriptions. The study was approved by the Geha Mental Health Center Helsinki Committee. We ensured that the questionnaire’s Hebrew translation was faithful to the original. After describing the nature of the study in detail to the participants, we obtained their written informed consent. We calculated means and standard deviations for each factor. The data were analyzed using SPSS statistical software. Unpaired Student’s t test and Bonferroni post-hoc test were used as appropriate.
One hundred out of approximately 160 Israeli residents (response rate=62.5%), from 15 programs, completed the questionnaire. The average age of the residents was 33.75±3.88 years old (the mean age of Israeli medical graduates was 32.51±2.49 years; the mean age of international medical graduates was 35.42±4.89 years). Demographic parameters and program description are summarized in Table 2
.
Table 3
lists the 10 items considered most important by the overall group of resident respondents in determining residents’ satisfaction with training programs. The two highest ranked items, "quality of supervision" and "respect of faculty for residents," scored much higher than the rest of the items.
When we divided the residents by gender, we did not find any significant difference between men and women for any selection factor (p=0.408). We did, however, find a significant difference between Israeli medical graduates and international medical graduates (F=3.498, df=39, 3081, p<0.001) for certain selected items. Israeli medical graduates assigned greater importance to "quality of supervision" (mean scores of 4.95±0.23 and 4.38±0.96 for Israeli medical graduates and international medical graduates, respectively, p=0.001) and to "respect of faculty for residents" (mean scores of 4.71±0.53 and 4.15±0.87 for Israeli medical graduates and international medical graduates, respectively, p=0.001). International medical graduates assigned greater importance to "professional abilities of program director" (mean 4.21±0.66 and 3.52±0.98 for international medical graduates and Israeli medical graduates, respectively, p<0.001) and "education prioritized over service" (mean 3.68±0.99 and 2.45±1.17 for international medical graduates and Israeli medical graduates, respectively, p<0.001).
We found concordance between residents’ theoretical orientation (biological, psychological, or eclectic) and the importance they attribute to focusing on that aspect as a factor in determining the satisfaction with their training. Most of the residents were eclectically oriented (Table 2
), and, as such, indicated that a "balance of training between psychosocial and biomedical aspects of psychiatry" was important in determining the overall quality of the training program. We were unable to demonstrate a shift in attitudes among residents with different years of residency
The study identifies what Israeli psychiatric residents consider to be the most important items in determining satisfaction with residency training programs. This list of items can be used by program directors when planning training programs. The two highest ranked items were "quality of supervision" and "respect of faculty for residents." To our knowledge, there are no similar Israeli studies on this subject for any specialty.
The items rated most highly by our sampling of residents are consistent with the finding of Elliott et al. (10) and of the 1987 findings of Haupt et al. (8). These similarities suggest that these are stable values for psychiatric residents over time. Although the modern practice of psychiatry has changed in the past decades (11, 12), psychiatric residents still value most the two domains of educational opportunities and educational ambience (10). Daugherty et al. (13) reached the same conclusion in a survey of satisfaction among 1,277 residents. Daugherty et al. (13) found that residents’ satisfaction increased with greater opportunities for learning and decreased the more the residents perceived that they were being mistreated. These findings imply that program directors should ensure that residents are being treated with respect and dignity, and are growing and developing professionally (12).
Comparing our results with Elliott’s study regarding subgroups, we found another similarity. Elliott et al. (10) found that residents, especially international medical graduates, considered "personal qualities of the program director" to be important in determining satisfaction with training (although this item was not included in the Resident Satisfaction Questionnaire since there was concern that it might pose problems for some program directors). Similarly, in our survey, the subgroup of international medical graduates graded "professional abilities of program director" second on the importance scale. However, the other participants ranked this item much lower. We believe that international graduates, being immigrants, may be more in need of role models than are native residents.
There were few differences between our results about Israeli residents and Elliott et al.’s (10) result about U.S. residents. The Resident Satisfaction Questionnaire presents two broad domains: educational opportunities and educational ambiance. Our results include these two domains, but also include other domains related to outcomes of the training program such as "job satisfaction of program graduates," and context that involves institutional and program resources such as "diversity of training settings" (1). We think that this difference is a result of the unique characteristics of the Israeli residents. The Israeli residents are older than American residents because of the 2 to 3 years of compulsory military service that usually predates their academic studies and residency (14). Furthermore, 40% of the residents are new immigrants, thereby required to repeat residency to gain the Israeli medical license. As a result, most of the residents are married and have families to support. Moreover, the group of new immigrants belongs largely to a lower socioeconomic class. We think that, because of these characteristics, Israeli residents have a more practical approach, and are more interested in the outcome of their training programs. They want to find satisfaction in their jobs, become competent psychiatrists, and be able to support their families. They also want to gain work experience in several settings, perhaps to enhance the chances of finding a job after completing their training.
Another difference between Israeli and American residents is that in the U.S. the board examinations are not mandatory as they are in Israel, where one cannot complete residency without passing the two formal residency exams (mid-residency written and final oral exams). Therefore, we expected that Israeli residents would rank "performance of graduates on residency exams" as one of the most important factors determining satisfaction in residency. However, similarly to the result of Elliott et al.’s (10) study, they did not. Perhaps residents attribute exam failure to themselves and not to the faculty.
A striking finding of our study and of other similar studies (3, 9, 10) is the fact that residents ranked factors such as "opportunities for research," "opportunities for teaching," "exposure to managed-care settings," and "interest in management," fairly low on the importance scale. Despite the many changes in the practice of psychiatry in the past decades (e.g., the introduction of managed mental health care to the field, the evolution of neuroscience, and greater demand for educating students), it seems that residents do not consider those alterations particularly important (11, 12). They are mostly interested in receiving education and being treated properly by the faculty. We speculate that this attitude is a result of the workload, stress, and burnout that characterize residency, causing most of the residents to take interest only in the activities that are part of the formal requirements of residency (7, 15). We advocate educational institutions emphasizing the changes occurring within psychiatry and encouraging residents to be more involved in the above mentioned fields.
There are a few limitations to the study. First, it is based on a relatively small sample size, as Israel is a small country with a limited number of psychiatric residents. Second, there may be a selection bias when distributing questionnaires by e-mail, as well as in the paper version. We tried to mitigate this by using the two different distribution methods.
Future research should compare the opinions of other stakeholders with those of the residents as to the most important indicators of program quality. It should also be interesting to explore what "quality of supervision" and "respect of faculty for residents" means to the residents.
At the time of submission, the authors disclosed no competing interests.