15th March 2013, Volume 126 Number 1371

Jonathon Foo, James Blackett, Jesse Gale, Maria Poynter

The training pathway for most New Zealand doctors requires a period of undergraduate study, prevocational work experience and then entry into a vocational training program for specialist training.

There are approximately 2124 vocational trainees comprising 16% of the total medical workforce.1,2 During their training these doctors deliver healthcare, and have an important service role in public hospitals.

Vocational trainees are specialists of tomorrow, so their quality of training, job satisfaction and demographics are important data, which contribute to workforce planning. Each specialist college assesses their own training program but there is evidence that an independent confidential survey may collect a less-guarded opinion from trainees.3

Here we aim to provide an independent anonymous assessment of vocational training quality in New Zealand, for the first time. Surveys in Australia and United Kingdom are available for comparison.4,5

Materials and Methods
For the purposes of this survey a vocational trainee was defined as a doctor enrolled in a vocational training program within a medical college, accredited by the Medical Council of New Zealand to provide vocational training.
colleges who attended the New Zealand Medical Association (NZMA) Trainee Forum in September 2011 were invited to participate, and they distributed the electronic survey to their vocational trainees by email between 16 December 2011 and 1 February 2012.
Separately, vocational trainee members of the NZMA were electronically invited to participate (98.2% contacted by email). There was no inducement or coercion to complete the online survey and responses were anonymous.
The content of the survey was duplicated from the Australian Medical Association’s 2010 Specialist Training Survey, which comprehensively covered questions that reflected both the Australian Medical Council and New Zealand Medical Council’s standards for vocational education and training.4 Additional questions were used to explore the viewpoints of extended absences of leave from vocational training in New Zealand.
Data analysis was performed using Prism 5.0d (GraphPad Software Inc, California, USA). The data were analysed as a single group of New Zealand vocational trainees to preserve anonymity. Mean values and 95% confidence intervals (95% CI) were calculated. Likert type questions had a range of 1-5; where 1=“strongly disagreed” to 5=“strongly agreed”, and results were expressed as a mean (where 3.0 represented neutral sentiment).
To compare with Australian data, a weighted average score (WAS) was also displayed, where -1.00 represents 100% of respondents strongly disagreeing, 0.00 represents neutrality, and +1.00 represents 100% strongly agreeing. The percentage who either agreed or strongly agreed with each statement was also calculated.

Results

General—The response rate was 24.8% (527 of 2124) with 86% of all respondents answering all questions. Respondents claimed membership of 13 colleges (Table 1 lists the colleges and their acronyms) of which 10 were bi-national colleges (Australian and New Zealand).

Thirty-six respondents (7%) described themselves as members of two colleges. Only RNZCGP trainees were under-represented (82 of 647 trainees responded, 12.7% response rate) and RACP trainees were over-represented (201 of 388 trainees responded, 51.8% response rate).

Table 1. Colleges whose trainees participated, with acronyms

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Overall 53% were female, and the largest age group was 30-35 years (47%). Seventy percent of trainees completed their primary medical degree in New Zealand. The next largest cohort obtained their degree from the United Kingdom (14.5%), and only 1.7% of surveyed trainees obtained their primary degree from Australia.

Overall 39% of trainees had children, and 77% were in either a de-facto relationship or married. Respondents represented a full spread of junior and senior trainees (Figure 1).

Figure 1. Year of vocational training in all respondents

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A total of 68% of surveyed trainees were based in the three major metropolitan cities (Auckland, Wellington and Christchurch) whilst 27% of trainees were based in smaller cities. Only 5% of trainees classified their location as either rural or remote.

Career choice and overall quality—The average time for trainees to decide on a career choice was 3.0 years after graduation. By the end of PGY2, 44% of trainees had decided on a vocational training program, 78% by the end of PGY4, and 13% took more than six years to decide.

Once in training, 90% of trainees were happy with their career choice and 69% of vocational trainees either strongly agreed or agreed that they were overall satisfied with their training program. Trainees were positive with the quality of their overall training program, the standard of training and their clinical experience during their training post (Table 2). The satisfaction about training was considerably less than the satisfaction with career choice (Table 2).

Selection criteria—Trainees agreed that the colleges had explicit criteria for selection into vocational training programs and secondly the colleges were fair and transparent about the process.

Examinations—Overall, trainees agreed that their colleges communicated well regarding examination details, but they were neutral regarding quality of examination feedback, and remediation (including the availability of resit examinations).

Flexible training options—Trainees agreed that overall, their college offered options for flexible training and supported trainees who used such options (Table 2).

Trainee wellbeing—Overall, trainees believed that their program supported safe working hours. Trainees were less satisfied in regards to policies of bullying, and college promotion of health and well-being. Trainees agreed that the colleges supported mentoring and an appropriate level of supervision; and had greater satisfaction with supervision than mentoring.

The costs of training—Overall, trainees were neutral about whether they experienced costs additional to their training program, and indicated these extra expenses did not cause financial hardship. Most vocational trainees who are employed in hospital settings have costs of training reimbursed, and clearly these registrars were less likely to indicate that training resulted in financial hardship than their community colleagues. Trainees did not feel that the costs of training represented value for money, whether they were paying for costs themselves or not.

Table 2. Weighted average scores (WAS) regarding opinions on quality of training
Question
% who agree or strongly agree
WAS
Mean
95%CI
Career Choice and Overall Quality




I am happy with my career choice
90
0.65
4.29
4.20–4.38
I am satisfied with my training program
69
0.39
3.69
3.62–3.78
I am satisfied with the standard of training I receive
76
0.41
3.82
3.74–3.90
My training posts provide the necessary clinical experience to meet the objectives of my training program
77
0.43
3.86
3.79–3.93

Selection into Training




The selection processes for entry into the training program are fair and transparent
72
0.40
3.81
3.73–3.88
The selection criteria for entry into the training program are clear and explicit
66
0.35
3.70
3.63–3.78

Examinations and Education




The college has a clear curriculum to guide my learning
66
0.32
3.65
3.58–3.71
I am able to attend regular college-recognised educational activities
63
0.26
3.53
3.44–3.62
I am given protected time to attend educational activities
55
0.16
3.31
3.20–3.42
I am able to access adequate conference and study leave to meet my training needs
64
0.29
3.57
3.48–3.66
The college-recognised educational activities offered are relevant and meet my training needs
66
0.34
3.67
3.60–3.75
The college-recognised educational activities offered are of good quality
64
0.34
3.69
3.62–3.7
I am able to access training in the private or community sector as part of my college training program
28
-0.14
2.70
2.60–2.80
The college utilises technology effectively in delivering its training program
45
0.10
3.21
3.13–3.30
The college communicates effectively with trainees about exams, including exam results
62
0.30
3.61
3.52–3.69
The college provides all candidates with detailed feedback about their exam performance
33
0.00
3.02
2.92–3.12
The college provides unsuccessful candidates with appropriate remediation
17*
-0.2
2.97
2.89–3.03
There are sufficient exam places to accommodate all eligible candidates
63
0.36
3.80
3.66–3.80
The exam is run frequently enough to progress through training without undue delay if I am unsuccessful at the first attempt
42
0.03
3.05
2.95–3.16
I pay for education and training in addition to that provided by my college training program, in order to meet my training needs
43
0.03
3.05
2.95–3.16
The exam content is set at an appropriate level for the trainees being assessed
67
34
3.68
3.60–3.75
The written exam content is relevant to clinical practice
52
0.18
3.35
3.27–3.43
The oral exam content is relevant to clinical practice
70
0.41
3.82
3.75–3.90
The other exam content is relevant to clinical practice
48
0.24
3.49
3.42–3.55
I have confidence in the validity of the oral exam as an assessment tool
58
0.25
3.51
3.42–3.60
The college provides exam candidates with adequate access to educational materials to prepare for exams
52
0.18
3.36
3.27–3.45

Flexible Training Options/Recognition of prior learning




The college offers appropriate flexible training options e.g. part-time and interrupted training
60
0.34
3.51
3.42–3.60
I feel the college supports those trainees who require access to flexible training options including parental leave
52
0.29
3.40
3.31–3.50
The training program’s limits on time to complete training adequately accommodates those trainees who access flexible training options
42
0.22
3.31
3.23–3.39
Accessing flexible training options would not disadvantage my career progression
52
0.25
3.39
3.30–3.48
The college has clear guidelines on recognition of prior learning policies and processes
45
0.20
3.24
3.16–3.33
The college grants appropriate credit (recognition of prior learning) for relevant prior training and experience
36
0.18
3.06
2.97–3.15
The lack of recognition of prior learning offered by my college has impacted negatively on my career progression
17
0.04
2.66
2.57–2.75

Trainee Wellbeing/Supervision




My college training requirements are compatible with safe working hours
76
0.39
3.78
3.70–3.86
The college promotes and supports trainee health and well being
53
0.23
3.47
3.38–3.55
The college has a clear policy on dealing with bullying and harassment
37*
0.15
3.30
3.23–3.38
The college responds in a timely and appropriate manner to cases of bullying and harassment
14*
0.04
3.08
3.03–3.13
Mandatory rotations are adequately flexible to accommodate the personal circumstances of trainees.
44
0.13
3.27
3.18–3.36
I feel isolated in my training location
13
-0.4
2.19
2.01–2.27
I am satisfied with the level of supervision I receive
79
0.43
3.87
3.79–3.95
I am satisfied with the mentoring I receive
66
0.33
3.65
3.56–3.73
I receive appropriate feedback which is useful in guiding my ongoing performance
68
0.32
3.65
3.56–4.73
Regular or interim appraisals and/or assessments are routinely conducted
74
0.39
3.77
3.69–3.85

Costs of Training




The costs of the college training program represent value for money
26
0.11
2.82
2.73–2.91
The costs of the college training program have caused me financial hardship
16
0.00
2.48
2.37–2.57

College Communication with Trainees




The college communicates well with trainees regarding issues that affect their training
56
0.18
3.36
3.27–3.46
The college gives trainees the opportunity to provide feedback on the training program and any proposed changes
56
0.21
3.42
3.33–3.50
I am confident that I will not be disadvantaged if I raise issues of concern with my college
48
0.14
3.29
3.20–3.37
The college actively seeks trainee input on training issues
57
0.25
3.49
3.41–3.57
The college responds to trainee concerns appropriately
35
0.09
3.19
3.11–3.26
The college effectively promotes the trainee representative and/or group
55
0.26
3.51
3.44–3.59
I am aware of how to contact my trainee representative group
57
0.20
3.39
3.30–3.49

*>50% of respondents answered “neither agree or disagree”.




Leave from training—A total of 25% of respondents had taken leave from medical employment. Out of this group 58% took less than a year of leave, 31% have taken between 1–2 years of leave and 7% have taken more than two years away from medical work (4% did not specify a duration). While 25% of trainees had taken leave from vocational training, 60% of all vocational trainees either strongly agreed or agreed that they would like to take extended leave if it was permissible by the colleges and Medical Council (Table 3). Several respondents also commented that they would be restricted from leave due to employer arrangements. Trainees desired to take extended leave for a variety of reasons (Figure 2).

Table 3. Viewpoints on extended leave from medical practice
Question
% who agree or strongly agree
WAS
Mean
95%CI
The college offers appropriate flexible training options e.g. part-time and interrupted training
60
0.34
3.51
3.42–3.60
I would like to take extended leave from medical practice, provided that it was acceptable to the Medical Council and my college
60
0.29
3.57
3.47–3.67
The Medical Council requirements for an extended absence from practice would prohibit me from taking leave of more than one year duration
30
0.09
3.18
3.11–3.25
My college's requirements would prohibit me from taking leave of more than one year duration
34
0.08
3.16
3.07–3.24
Figure 2. Reasons for desiring extended leave

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Black bar: overall trainee response. Grey bar: male trainees. White bar: female trainees.

Discussion

New Zealand vocational trainees appear to have an overall positive opinion of their training. Approximately 90% of respondents were happy about their career choice, and 69% were positive about their training program. These results are consistent with Australian surveys, where 88% and 68% of vocational trainees responded similarly to these questions.4

The MABEL longitudinal survey of Australian doctors found 85% job satisfaction amongst vocational trainees.6 British vocational trainees had 82.6% overall satisfaction with their training, which appears higher than in Australasia but the percentage was measured with five different questions.5

This survey noted key themes across training programs. Specific issues such as selection, the alignment of clinical experience with training objectives, college communication, safe hour guidelines and supervision were given a high level of satisfaction by trainees. It was important to find that New Zealand was not perceived as lacking in any areas of training quality when compared to Australia or United Kingdom.4,5

Issues of concern—Trainees were dissatisfied or neutral about access to the private sector for training purposes and whether the cost of the trainee program was value for money.

There is an ongoing discussion about how certain elements of medicine, particularly some surgical procedures, are increasingly isolated to the private sector.7 When training has occurred exclusively in the public sector, this raises the issue of how to train the future workforce for work that may only be undertaken in the private sector .

There are challenges regarding training in the private sector, and it remains largely an unmet desire for trainees according to our survey. There may be innovative funding models which support training in the private sector, such as the Waitemata District Health Board joint arthroplasty pilot8 but further data are needed.

Only 26% of trainees see training programs as value for money, despite the fact that many of the costs of their training are reimbursed by employers due to the current collective employment agreement. This may reflect costs that were not reimbursed, or a perception that the fees that are paid by employers were unjustified.

Our results compared favourably to Australia, where costs of training are not reimbursed, and thus many more Australian trainees felt that training was not value for money.4 Most of the bi-national colleges have the same fees and services between countries, indicating the relative effect of this reimbursement clause on the satisfaction of New Zealand trainees. Nonetheless, the dissatisfaction of New Zealand trainees with value suggests transparency and fairness remain important issues here.

Work-life balance—Work life balance is of growing importance for many doctors in training. The majority of respondents were either married or in a de facto relationship (77%) and more than a third (39%) had children. Demographics were very similar in Australia.4Overall, trainees felt that their respective colleges provided options for flexible training, including parental leave, and that taking up flexible training options did not disadvantage trainees.

More than half of respondents (60%) would have liked to take extended leave of absence. The reasons for extended leave were varied, and offer a perspective on the intentions and work-life balance of trainees (Figure 2). A majority would take time out for parental and family leave, and for academic research, and many respondents (>40%) would take leave for travel, overseas employment and different work-life balance.

The large number of respondents who desired extended leave was contrasted by the relatively small number of respondents (8.5%) who have actually taken leave for more than one year. Many respondents believed that either the Medical Council or their college prohibited extended leave. This perception may be preventing many from fulfilling their desire to take a non-linear pathway through their vocational training.

If more trainees were to pursue interrupted training and extended leave, it would certainly have implications on workforce planning and the design of training programmes.

Comparison to Australia—Most of the respondents were from Australasian (bi-national) colleges, and yet New Zealand respondents were positive about college communication and the potential for them to feedback and influence college policies.

In addition to issues of cost and value, New Zealand trainees expressed greater satisfaction than their Australian peers in response to the same questions on various aspects of training. Specifically in areas of examination content, feedback and remediation, training flexibility, institutional bullying, recognition of prior learning, and access to courses, the New Zealand respondents indicated greater satisfaction than Australians.4

Further analysis was limited because of the low response rate of the Australian survey, where there were only 538 respondents out of the 10,649 trainees’ pool (5.1%).9

Limitations—Our survey targeted New Zealand vocational trainees (16% of the medical workforce), and had a response rate of 25% (n=527). Of course such samples are subject to selection bias, but this is a sizable sample size relative to previous attempts to assess the sentiments of trainees at a national level.4

Publically available demographic data on vocational trainees is limited and this survey is provides some further insight. Health workforce numbers in 2009 describe 52% of all vocational trainees are men and 48% are women;1 this compares to our survey respondents where 53% were women. To our knowledge this is the first national survey on the sentiment of New Zealand’s vocational trainees.

Likert scores also prevent analysis of issues that affect only a small number of respondents. Some answers were meaningless, such as a high number of trainees who “neither agree or disagree” that their college has satisfactory measures to prevent bullying. These errors in study design were in part overlooked to maintain the same questions as the Australian survey.

Summary

Overall, New Zealand vocational trainees were satisfied with their career and training. This is a positive outcome, particularly given the nature of our bi-national colleges, and the importance of training in retention of doctors. The emerging desire for varied extended leave may reflect changes in how trainees see their career possibilities. This survey provides a useful baseline for assessing the perceptions of trainees in years to come.

Summary

We surveyed New Zealand vocational trainees using an online questionnaire Trainees expressed a high level of satisfaction with most aspects of their training, and results compare favourably with Australia. Access to training in the private sector, and value for money emerged as areas of concern, but also highlight the importance of reimbursed costs in the satisfaction of New Zealand trainees. Work life balance is of increasing importance to young doctors, and an unmet desire for extended leave from medical practice may present an issue for workforce capacity and training flexibility in years to come. This survey provides a snapshot, a baseline and useful demographic data for future comparisons.

Abstract

Aim

To assess the opinions of New Zealand vocational trainees about the quality of their training.

Method

We surveyed New Zealand vocational trainees using an online questionnaire based on the Australian Medical Association Specialist Trainee Survey, in September and October 2011.

Results

The response rate was 24.8% with representation across training programs. Trainees expressed a high level of satisfaction with most aspects of their training, and results compare favourably with Australia. Access to training in the private sector, and value for money emerged as areas of concern, but also highlight the importance of reimbursed costs in the satisfaction of New Zealand trainees. Work life balance is of increasing importance to young doctors, and an unmet desire for extended leave from medical practice may present an issue for workforce capacity and training flexibility in years to come.

Conclusion

This survey provides a snapshot and a baseline, for future comparisons.

Author Information

Jonathan Foo, General Surgical Trainee, Taranaki Base Hospital, New Plymouth; Jesse Gale, Ophthalmology Trainee, Greenlane Clinical Centre, Auckland; Maria Poynter, Public Health Trainee, Regional Public Health, Wellington; James Blackett, Orthopaedic Trainee, Southland Hospital, Invercargill

Correspondence

Dr Jonathan Foo, General Surgery, Taranaki Base Hospital, Weston, 4310, New Plymouth, New Zealand.

Correspondence Email

joa305@gmail.com

Competing Interests

Nil.

References

  1. Health Workforce New Zealand. Vocational Training of Medical Workforce. 2009; http://www.healthworkforce.govt.nz/tools-and-resources/for-employers-educators/workforce-statistics-and-information/medical-workforce/training
  2. Medical Council of New Zealand. MCNZ Annual Report 20112012.
  3. Nash-Stewart C. Medical training providers obtaining feedback from their trainees: what is best practice? Prepared for the Australian Medical Council workshop: Training Program Evaluation and Trainee Feedback 13 November 2010.http://workshop.amc.org.au/wp-content/uploads/2010/10/Trainee-Feedback-Best-Practice-FINAL.pdf
  4. Australian Medical Association specialist trainee survey: report of findings. October 2011. http://ama.com.au/specialist-trainees-survey
  5. General Medical Council national training survey 2012. July 2012. http://www.gmc-uk.org/National_training_survey_2012_key_findings_report.pdf_49280407.pdf
  6. Joyce CM, Schurer S, Scott A, et al. Australian doctors' satisfaction with their work: results from the MABEL longitudinal survey of doctors. Med J Aust. Jan 3 2011;194(1):30–3.
  7. Collins JP, Civil ID, Sugrue M, et al. Surgical education and training in Australia and New Zealand. World J Surg. Oct 2008;32(10):2138–44.
  8. Cullen J, Bramley D, Armstrong D, et al. Increasing productivity, reducing cost and improving quality in elective surgery in New Zealand: the Waitemata District Health Board joint arthroplasty pilot. Intern Med J. Jun 2012;42(6):620–6.
  9. Mitchell RD, Markwell A, Fielke RJ et al. The 2010 Specialist Trainees Survey, a view from the front line. Med J Australia. Oct 2011;195(7):382.