Cannon_Keitz_Holland_Factors Med Student (TOC)

Cannon_Keitz_Holland_Factors satisfaction med student resident LPS_2008.pdf

Learner's Perception (LP) Survey

Cannon_Keitz_Holland_Factors Med Student (TOC)

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Cannon, Keitz, Holland, Factors Satisfaction Med
Student Resident LPS 2008.pdf
Factors Determining Medical Students’ and
Residents’ Satisfaction During VA-Based
Training: Findings from the VA Learners’
Perceptions Survey

This document is in reference to the non-response bias analysis requested
by OMB. OMB made a second request for the lead Statistician to expound
on their previous response, by providing more detail.

Medical Education

Factors Determining Medical Students’ and
Residents’ Satisfaction During VA-Based
Training: Findings from the VA Learners’
Perceptions Survey
Grant W. Cannon, MD, Sheri A. Keitz, MD, PhD, Gloria J. Holland, PhD,
Barbara K. Chang, MD, MA, John M. Byrne, DO, Anne Tomolo, MD, MPH,
David C. Aron, MD, MS, Annie B. Wicker, and T. Michael Kashner, PhD, JD, MPH

Abstract
Purpose
To compare medical students’ and
physician residents’ satisfaction with
Veterans Affairs (VA) training to
determine the factors that were
most strongly associated with trainee
satisfaction ratings.
Method
Each year from 2001 to 2006, all medical
students and residents in VA teaching
facilities were invited to complete the
Learners’ Perceptions Survey. Participants
rated their overall training satisfaction on
a 100-point scale and ranked specific
satisfaction in four separate educational
domains (learning environment, clinical
faculty, working environment, and
physical environment) on a five-point

Medical education involves a

spectrum of learning activities
characterized by educational experiences
that ideally are organized around the
evolving needs of the learner. The
progression from undergraduate medical
school training through graduate medical
education involves graduated levels of
medical knowledge, clinical experiences,
and responsibilities. The design of
effective educational experiences requires
an understanding of the factors most
associated with trainee satisfaction and
the differences in the learning needs of
trainees by level of training. Previous
work has identified striking similarities in
faculty/preceptor characteristics that are
valued by different levels of undergraduate

Please see the end of this article for information
about the authors.
Correspondence should be addressed to Dr. Cannon,
Associate Chief of Staff for Academic Affiliations,
George E. Wahlen VA Medical Center, 500 Foothill
Boulevard (Mail Code 11E), Salt Lake City, UT 84148;
telephone: (801) 584-1277; fax: (801) 584-2559;
e-mail: ([email protected]).

Academic Medicine, Vol. 83, No. 6 / June 2008

Likert scale. Each domain was composed
of unique items.
Results
A total of 6,527 medical students and
16,583 physician residents responded to
the survey. The overall training
satisfaction scores for medical students
and physician residents were 84 and 79,
respectively (P ⬍ .001), with significant
differences in satisfaction reported across
the training continuum. For both medical
students and residents, the rating of
each of the four educational domains
was statistically significantly associated
with the overall training satisfaction score
(P ⬍ .001). The learning environment
domain had the strongest association with
overall training satisfaction score, followed

and graduate medical trainees, such as
enthusiasm, willingness to delegate
responsibility, and providing feedback.1
Preceptor interactions were identified as
more highly valued by medical students
than by medical residents, who, in contrast,
believed that the variety of patients and
evaluating patients independently were
more important. Research has shown that
differences in learning resource needs and
perceptions of preparedness for residency
also varied across the spectrum of medical
students and residents.1
Trainee satisfaction has been routinely
employed as an outcome measure
in evaluating faculty performance
and the impact on learners’ training
experiences.1–3 Prior work in the area of
trainee perceptions has focused on the
themes of satisfaction with teaching style
and role models, as well as the influence
of clinical rotations on choice of specialty
training. Teaching styles and practice
characteristics in the ambulatory setting
have also been emphasized.1,2 Whereas
prior work has compared undergraduate

by the clinical preceptor, working
environment, and physical environment
domains; no significant differences were
found between medical students and
physician residents in the rank order.
Satisfaction with quality of care and faculty
teaching contributed significantly to
training satisfaction.
Conclusions
Factors that influence training
satisfaction were similar for residents and
medical students. The domain with the
highest association was the learning
environment; quality of care was a key
item within this domain.
Acad Med. 2008; 83:611–620.

and postgraduate trainees in common
clinical settings (e.g., the ambulatory
clinic), broader comparisons are lacking.
The identification of other factors beyond
preceptor characteristics that contribute
to the satisfaction of trainees working in a
variety of clinical settings will facilitate
the development of effective educational
experiences.
The Department of Veterans Affairs (VA)
Learners’ Perceptions Survey (LPS) was
developed to measure the satisfaction of
all trainees at VA facilities. Since 2001,
the LPS has been completed by more
than 70,000 VA-based trainees in
multiple disciplines, of whom more
than 23,000 were residents and medical
students. The LPS is a validated instrument
that provides a comprehensive evaluation
of the perceptions of undergraduate and
graduate trainees related to their clinical
training. Simultaneously, the LPS identifies
key factors associated with the satisfaction
of medical trainees who are working in the
same training environment, that is, a VA
medical facility.3

611

Medical Education

VA clinical training provides an ideal
opportunity to compare factors influencing
trainee satisfaction for medical students
and physician residents. The education of
health care professionals is one of the four
congressionally mandated missions of the
Veterans Health Administration, yet until
the development of LPS there was no clear
measurement of trainees’ satisfaction with
their educational experiences in the VA.
Each year, an estimated 17,000 medical
students and more than 30,000 physician
residents rotate through 125 VA hospitals
affiliated with more than 100 medical
schools.4 The VA funds approximately
8.5% of all U.S. postgraduate positions in
Accreditation Council for Graduate
Medical Education-accredited training
programs.4 In their VA educational
experiences, medical students and
physician residents share common
patients, faculty, and work environments.
In this study, we evaluated the data from
the LPS to achieve three objectives: (1) to
compare the overall level of satisfaction
of medical students against that of
residents during VA-based training, (2)
to identify, from a broad array of
domains and items, the factors most
strongly associated with medical student
and resident satisfaction with their
training, and (3) to determine whether
the factors (domains and items)
associated with training satisfaction for
medical students and physician residents
are different.

overall training satisfaction score and to
assess levels of satisfaction in four
educational domains: clinical faculty or
preceptor, learning environment, working
environment, and physical environment.
Each of these four domains encompasses
specific items that were determined
through multiple regression analyses to
contribute to the overall training
satisfaction score for the domain.3 The
items are fully listed in Appendix 1.
When implemented in April 2001 and
continuing in each annual survey to the
present time, the LPS included the four
domains and their associated items. For
each of the items, respondents rated their
satisfaction with their VA training
experience using a five-point Likert scale
(5 ⫽ very satisfied, 4 ⫽ somewhat
satisfied, 3 ⫽ neither satisfied nor
dissatisfied, 2 ⫽ somewhat dissatisfied,
and 1 ⫽ very dissatisfied). Trainees also
rated their overall satisfaction with each
of the four educational domains on a
similar five-point Likert scale after
evaluating each item within its respective
domain.
Over time, additional questions have
been added to the LPS to explore the
impact of changes in the clinical
education environment on trainee
satisfaction. For the current analysis, we
only evaluated the components of the
survey that have been unchanged since its
implementation in 2001.

Method

Outcome measures

Survey development

For an overall VA training satisfaction
score, trainees answered the following
question: “On a scale of 0 to 100, where
100 is a perfect score and 70 is a passing
score, what numerical score would you
give your most recent VA clinical training
experience?” The numerical response to
this question is the “overall training
satisfaction score” and is one of the
primary outcome measures used in this
analysis.

The VA LPS was developed to examine
and measure learner satisfaction for all
health care trainees in the VA system.
The development and initial use of the
LPS has been described and previously
reported.3 In brief, the survey was
developed beginning in 1999 under the
sponsorship and guidance of the Office of
Academic Affiliations (OAA) of the VA.
The use of the LPS to meet an educational
performance measure was an explicit part
of the rationale for the survey. An advisory
committee of VA educational leaders was
assembled by the OAA to develop the LPS.
After a systematic review of the literature
on learner satisfaction, potential domains
and items were identified. The survey was
pilot tested in more than 1,000 trainees
from 22 geographically diverse VA medical
centers. On the basis of pilot testing, the
survey design was refined to provide an

612

Other measures include the four
educational domains: clinical faculty/
preceptor, learning environment,
working environment, and physical
environment. The decision to include the
overall training satisfaction score and
four domains was made a priori to
capture the dataset that was continuously
present since the first implementation of
the survey in 2001.

Study design
The current report presents survey
results from a six-year summary analysis
of the annual LPS surveys of trainees’
satisfaction with their training
experiences at VA medical centers
from 2001 through 2006.
Study population
We invited all medical students and
physician residents involved in a course
of undergraduate or graduate medical
education and rotating at least once
during the academic year to any VA
teaching facility to complete the LPS,
beginning in the spring of 2001. Medical
students and physician residents who
responded to the survey were included
in this study if they completed the
following LPS items: the overall training
satisfaction score, all four domain scores,
their level of medical training, and status
as an undergraduate or graduate medical
trainee.
Survey administration and number of
eligible participants
In 2001, trainees registered to participate
in the survey through a postcard
registration process. Registered trainees
were mailed a paper survey or could
complete an online version of the survey.
For all other years of the survey, there
was no separate registration process;
rather, we encouraged all physician
trainees (medical students and residents)
rotating at least once at a VA facility to
participate in the survey through a
combination of national and local
recruitment efforts. Nationally, letters of
information and invitation were sent out
from the OAA to all physician trainees
for whom addresses were available during
the first four years of the survey, with an
emphasis on completing the survey in
April of each academic year. In addition,
individual VA facilities were encouraged
to develop complementary local
processes to encourage trainee
participation in the survey. Local
processes for trainee recruitment varied.
The survey was available in both paper
and online versions in 2001 through
2003. Since 2004, the survey has been
administered only online.
We can only estimate the number of
medical students and physician residents
eligible to take the LPS. In fiscal year
2006, the VA sponsored 8,851 residency
positions4; however, because each

Academic Medicine, Vol. 83, No. 6 / June 2008

Medical Education

resident trainee position may be filled by
more than one trainee during the course
of a year, the exact number of residents
on rotation in the VA is imprecise.
Furthermore, because the administration
of the survey involved direct mailing and
e-mail communications with trainees
who have very dynamic contact
information, we were unable to verify
whether the request for survey
participation was actually received by all
potential participants. Both of these
factors impair our ability to make a
precise estimate of the effective pool of
trainees who were available to take the
survey and received an invitation.
Analyses
Mixed-effects models were used to
compute the association between
individual items on domain scores and,
in turn, the association of differences in
domain scores with differences in facilitywide satisfaction scores. Models were
adjusted for nesting of respondents
among 125 facilities and during six years
of assessments from 2001 through 2006.
Adjusting for individual respondents
was not possible because individual
responders were anonymous. Medical
students were not asked to specify the
clinical rotation at the VA (e.g., internal
medicine, surgery, psychiatry, etc.). Thus,
an adjustment for program specialties
was not available for medical students
and, hence, for consistency, was not used
for medical residents.
To evaluate overall training satisfaction
scores, tested variables included the main
effect of medical student status and mean
centered domain scores for each of the
four domains, and the respective medical
student status by mean centered domain
score interactions for each of the four
domains. We computed means for each
domain across both resident and medical
student scores.
To assess factors associated with domain
scores, main effects included medical
student status and mean centered item
scores for each item, and the corresponding
medical student status by mean centered
item score interactions. The learning
environment domain encompassed 15
items, 13 items each for clinical preceptors
and work environment, and 12 items for
physical environment. We computed
means for each item across both residents
and medical student scores within each
respective domain. The differences in

Academic Medicine, Vol. 83, No. 6 / June 2008

associations for residents and medical
students were calculated as mean
differences.
Tests for content validity and internal
consistency
The items comprising each of the LPS four
domains have been assessed for both
content validity3 and for internal
consistency. According to these data,
respondents’ answers met reliability criteria
for the 15-item learning environment
domain (␣ ⫽ 0.93, n ⫽ 15,054), the 13item clinical faculty/preceptors domain
(␣ ⫽ 0.96, n ⫽ 11,569), the 13-item
working environment domain (␣ ⫽ 0.91,
n ⫽ 15,707), and the 12-item physical
environment domain (␣ ⫽ 0.89,
n ⫽ 14,409).
We performed additional analyses to
assess reliability for the items of other
domains included in the LPS. These
include internal inconsistency for the 15
items comprising clinical environment of
␣ ⫽ 0.94 (n ⫽ 9,259), 9 items comprising
clinical training experience of ␣ ⫽ 0.87
(n ⫽ 18,046), 13 items comprising
assessment of the availability and timeliness of staff and services of ␣ ⫽ 0.93
(n ⫽ 10,190), 13 items comprising
personal experience of ␣ ⫽ 0.94
(n ⫽ 11,856), 6 items comprising the
quality of staff and services of ␣ ⫽ 0.86
(n ⫽ 15,153), and 6 items of systems and
process in dealing with medical errors of
␣ ⫽ 0.96 (n ⫽ 13,308).
Statistical significance
All statistical procedures were performed
using a standard statistical software
package (Statistical Package for the Social
Sciences version 13 and Hierarchical
Linear Models version 5). Because of the
multiple analyses, we considered findings
to be statistically significant at a P ⬍ .001
level. In reporting the association of
different items on the domain score,
the items with a P ⬍ .001 statistically
significant association and a ⬎ 0.1 impact
on domain score for either medical
students or residents were considered
significant and were reported.
Ethical considerations
The U.S. Office of Management and
Budget, which reviews and approves
federal-government-sponsored surveys,
approved our survey. We maintained
confidentiality by keeping respondents’
information in a separate database

and reviewing only aggregate data.
Participation in the survey was
completely voluntary. The confidential
nature of the data collection and
voluntary participation were fully
disclosed to survey participants.

Results

Overall training satisfaction score
During the six-year observation period,
23,110 medical students and physician
residents from 125 VA facilities
participated in the LPS (Table 1). The
best estimate for response rate, based on
the number of funded resident positions,
is 31% for medical residents, with a
similar response rate estimated for
medical students. The mean overall
training satisfaction scores of medical
students and physician residents were
83.6 and 79.1, respectively (P ⬍ .001)
(Table 2). After correcting for differences
in the distribution of medical students
and residents across 125 VA facilities
and by survey year, medical students
continued to have higher overall training
satisfaction scores than residents, with a
mean difference of 4.6 points (P ⬍ .001)
(Table 2).
Respondents’ levels of training influenced
their overall training satisfaction scores
(Figure 1). Adjusting for facility and
survey year, medical students’ satisfaction
decreased from the first to the fourth
year. (⌬ ⫽ ⫺0.67/year, 95% CI [⫺1.04,
⫺0.30], t ⫽ 3.54, P ⬍ .001). In contrast,
physician residents’ satisfaction scores
were found to increase with level of
training advances (⌬ ⫽ 0.54/year, 95%
CI [0.26, 0.83], t ⫽ 3.8, P ⬍ .001). In fact,
PGY4 through PGY7 residents assigned
higher overall training satisfaction scores
to facilities than PGY1 through PGY3
residents (80.44 for PGY4 through PGY7
versus 78.92 for PGY1 through PGY3,
⌬ ⫽ 1.52, 95% CI [0.71, 2.34], t ⫽ 3.7,
P ⬍ .001).
Association of domain satisfaction score
with overall training satisfaction score
For medical students and residents,
each domain’s score had a statistically
significant association with overall training
satisfaction score rating (P ⬍ .001)
(Table 2). Domain score effects on overall
satisfaction varied for the four different
domains, but they were rank-ordered
similarly by medical students and

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Medical Education

Table 1
Number of Responders by Year of Survey and Level of Training for Medical
Students and Physician Residents, from a Study of Learners’ Satisfaction With
Their Veterans Affairs (VA) Training
Responses, by type

No. (%)

Year

2001

1,744 (7.5)

2002

2,858 (12.4)

2003

3,950 (17.1)

2004

3,917 (16.9)

2005

4,356 (18.8)

2006

6,285 (27.2)

Total

23,110 (100.0)

Medical students

First year

818 (3.5)

Second year

308 (1.3)

Third year

3,437 (14.9)

Fourth year

1,964 (8.5)

Total medical students

6,527 (28.2)

Physician residents*

PGY-1

4,659 (20.2)

PGY-2

3,729 (16.1)

PGY-3

3,627 (15.7)

PGY-4

2,516 (10.9)

PGY-5

1,239 (5.4)

PGY-6

599 (2.6)

PGY-7

214 (0.9)

score was higher for physician residents
than for medical students, although this
difference did not achieve statistical
significance.
Association of items of domain score
We calculated the scores for the
individual items in each domain and the
effects of the individual items of each
domain on the overall domain score
(Table 3). Results were analyzed
separately for medical students and for
residents; we report the difference in each
item’s effect on the overall domain score
by respondent. After correcting for
differences in the distribution of medical
students and residents by VA facilities
and survey year, medical students
assigned higher domain scores than
residents for learning environment and
working environment (P ⬍ .001).
Analysis showed that the satisfaction
ratings for the majority of items in each
of the domains were highly correlated
with the overall domain score for medical
students as well as residents.

Total physician residents

16,583 (71.8)

Total

23,110 (100.0)

* PGY, postgraduate year.

residents. For medical students and
residents, the learning environment
domain had the largest association with

overall training satisfaction score. The
learning environment domain score’s
impact on the overall training satisfaction

The key items contributing to the
learning environment domain score were
preparation for future training and
quality of care. The impact of the qualityof-care item on the learning environment
domain score was higher for physician
residents than for medical students,
although this result did not achieve
statistical significance (P ⫽ .002). The
quality and teaching ability of clinical
faculty were key items determining the
clinical faculty/preceptor domain. Work

Table 2
Overall Training Satisfaction Scores and Domain Effect on Overall Satisfaction
Scores for 6,527 Medical Student and 16,583 Physician Resident Responders to a
Survey of Their Satisfaction With Their Veterans Affairs (VA) Training Experience
Physician residents

Medical students
Category

Mean (95% CI)
*

Mean (95% CI)

Overall score

83.6 (83.2–83.9)

79.1 (78.9–79.3)

Corrected overall score†

83.9 (83.2–84.5)

79.5 (78.9–80.1)

‡

Effect size

Learning environment

4.47 (3.96–4.98)

17.1

⬍.001

5.23 (4.89–5.57)

30.6

⬍.001

Clinical faculty

2.86 (2.40–3.31)

12.4

⬍.001

2.75 (2.44–3.06)

17.5

⬍.001

Working environment

1.46 (1.00–1.91)

6.3

⬍.001

2.13 (1.82–2.44)

13.5

⬍.001

Physical environment

1.47 (1.08–1.85)

7.5

⬍.001

1.53 (1.24–1.83)

10.5

⬍.001

* Overall training satisfaction score: “On a scale of 0 to 100, how would you rate your VA training experience,
with 70 being a passing score?”
†
Corrected means are adjusted for annual (2001–2006) and facility (125 medical centers) nesting.
‡
Effects are the associated difference in overall training satisfaction score (100-point scale) per each difference in
domain score (five-point scale). Data are corrected for annual and facility nesting.

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Academic Medicine, Vol. 83, No. 6 / June 2008

Medical Education

Overall Score (corrected)

88
86
84
82
80
78
76
MS-1

PGY-1

Medical student by year

Physician resident by year

Figure 1 Overall training satisfaction scores for VA training experience by year of training for
medical students (MS) (years one through four) and postgraduate year (PGY) physician residents,
years one to seven. Values presented are corrected for nesting within facility and year of
collection.

space, peer group and faculty morale,
and facility maintenance upkeep and
cleanliness were important items for both
residents and medical students for the
working environment and the physical
environment domains, respectively.
Medical students reported a higher
percentage of very satisfied responses to
the domain scores (learning
environment, clinical faculty/preceptor,
working environment, and physical
environment). When we evaluated the
individual items within each domain,
the medical students rated 51 of the 53
items higher compared with residents ’
responses. The percentage of very satisfied
responses for the approachability/openness
and accessibility/availability items in the
clinical faculty/preceptor domain was lower
for the medical students than for the
physician residents (see Appendix 1).
Discussion

Three key observations can be made from
our findings. First, the reported level of
trainee satisfaction was higher for
medical students than for residents in a
common training environment, with
differences in satisfaction occurring as
medical students and residents advanced
in their training while in a common
training environment. Second, the
domains and items associated with the
overall satisfaction with VA-based
training of medical students and
physician residents were similar. Third,
the learning environment domain rating
had the strongest association with
learners’ overall training satisfaction,
whereas ancillary matters associated with

Academic Medicine, Vol. 83, No. 6 / June 2008

the physical environment were found to
be less important. The associations found
were very similar for both medical
students and residents. In the learning
environment and clinical faculty
domains, the quality of care and quality
of faculty were the most important items.
These findings are important because, to
our knowledge, ours is the first study to
simultaneously compare multiple
domains of trainee satisfaction in a
common clinical training environment
through a serial cross-sectional national
survey of medical students and residents.
The LPS is a comprehensive satisfaction
survey that permits evaluation and
comparison of perceptions of clinical
training experiences across the entire
continuum of medical education. This
six-year summary analysis of the LPS
shows that, while varying in the degree
of satisfaction, the basis for medical
students’ and residents’ perceptions of
their VA training was very similar overall.
Although overall satisfaction was highest
among medical students, overall
satisfaction varied across the continuum
of medical education. Satisfaction was
highest early in medical school and
lowest during the first postgraduate year
of residency.
Much of the literature on both medical
student and resident physician
satisfaction has focused on individual
teachers’ behaviors and styles1,5–7 as
important measures of educational
effectiveness. Unlike other surveys of
trainee perceptions, the LPS looks
beyond the role of teaching and role

models in evaluating satisfaction with
clinical training. Learning environment
(hands-on, clinical training), working
environment (support, ancillary staff and
equipment), and physical environment
domains are all incorporated into the
LPS. Our results suggest that, at least in
the VA setting, the learning environment
has the greatest influence on learners’
overall training satisfaction, and the
physical environment, working
environment, and clinical faculty
domains are less important. Although
medical students’ and residents’
perceptions were similar, the effect of
the learning environment domain on
the overall satisfaction score was higher
for residents. While this difference
approached statistical significance, the
contribution of the learning environment
domain on medical students’ overall
training satisfaction score may be limited
by the “ceiling effects” of the higher
medical student overall training
satisfaction scores.
Previous studies have suggested that
many individual items measured by the
LPS’s working environment domain and
clinical faculty/preceptor domain are
important to medical students’ and
resident physicians’ satisfaction with their
clinical education.1–3,5–7 Items within the
LPS’s learning environment domain such
as autonomy, supervision, and spectrum
of patient problems have also been associated with learners’ satisfaction.1,3,8 –11
The LPS data further suggest that the
satisfaction of medical students and
physician residents with the learning
environment is significantly influenced
by the perceived quality of health care
provided at the facility. VA health care
has changed dramatically in the last
decade, with documented improvements
in the quality of care as reflected in a
broad range of performance measures,
such that currently, the VA mostly
exceeds private-sector performance.12,13
The data we have presented here
may indicate that medical students
and residents recognize the VA’s
improvement in quality indicators. In a
broader sense, quality of care may be an
underappreciated item in medical students’
and resident physicians’ satisfaction with
their training. Given their direct, daily,
hands-on patient contact, medical students
and residents may be uniquely positioned
to perceive and assess the quality of care

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Table 3
Effect of Each Item on Domain Scores for 6,527 Medical Students and 16,883
Physician Residents, and Difference in Effect Size Between Medical Student and
Physician Residents from a Survey of Their Satisfaction With Their Veterans
Affairs (VA) Training
Medical students
Domain score

Mean (95% CI)

Physician residents
P

Mean (95% CI)

Learning environment

Mean

4.22 (4.20–4.25)

3.93 (3.91–3.94)

Adjusted–corrected mean*

4.05 (4.03–4.06)

4.00 (3.99–4.01)

Effects†

Preparation for future training

0.15 (0.12–0.18)

10.3

⬍.001

0.14 (0.12–0.16)

14.0

⬍.001

Quality of care

0.14 (0.12–0.16)

13.3

⬍.001

0.18 (0.17–0.20)

23.2

⬍.001

Time for learning

0.11 (0.09–0.13)

11.8

⬍.001

0.09 (0.08–0.10)

14.4

⬍.001

Preparation for clinical practice

0.10 (0.07–0.13)

6.5

⬍.001

0.12 (0.10–0.13)

11.7

⬍.001

Preceptor/faculty

Mean

4.37 (4.35–4.39)

4.22 (4.21–4.23)

Adjusted–corrected mean*

4.28 (4.27–4.29)

4.26 (4.25–4.27)

Effects†

Quality of faculty

0.19 (0.17–0.22)

15.2

⬍.001

0.22 (0.20–0.23)

23.4

⬍.001

Teaching ability

0.15 (0.12–0.18)

9.9

⬍.001

0.15 (0.13–0.17)

14.8

⬍.001

Clinical skills

0.12 (0.09–0.14)

8.7

⬍.001

0.08 (0.06–0.10)

8.4

⬍.001

Working environment

Mean

4.10 (4.07–4.12)

3.77 (3.76–3.79)

Adjusted–corrected mean*

3.97 (3.92–3.96)

3.87 (3.86–3.88)

Effects†

Workspace

0.14 (0.12–0.16)

13.5

⬍.001

0.15 (0.14–0.16)

23.8

⬍.001

Peer group morale

0.12 (0.10–0.15)

9.1

⬍.001

0.12 (0.11–0.14)

16.2

⬍.001

Faculty/preceptor morale

0.11 (0.08–0.13)

8.2

⬍.001

0.10 (0.08–0.11)

13.4

⬍.001

Computerized Patient Record System
(CPRS)

0.10 (0.07–012)

7.2

⬍.001

0.09 (0.08–0.10)

13.0

⬍.001

Ancillary/support staff

0.09 (0.07–0.11)

7.4

⬍.001

0.11 (0.10–0.13)

15.4

⬍.001

Laboratory services

0.06 (0.04–0.08)

5.5

⬍.001

0.10 (0.08–0.11)

14.1

⬍.001

Physical environment

Mean

4.03 (4.01–4.06)

3.78 (3.76–3.79)

Adjusted–corrected mean*

3.83 (3.82–3.85)

3.82 (3.81–3.83)

Effects†

Facility maintenance/upkeep

0.15 (0.12–0.18)

9.4

⬍.001

0.16 (0.14–0.17)

17.6

⬍.001

Facility cleanliness/housekeeping

0.15 (0.13–0.18)

11.7

⬍.001

0.11 (0.10–0.13)

15.3

⬍.001

Call rooms

0.12 (0.10–0.14)

13.5

⬍.001

0.13 (0.12–0.15)

25.0

⬍.001

Availability of food on call

0.11 (0.10–0.12)

16.5

⬍.001

0.11 (0.10–0.12)

25.1

⬍.001

Availability of needed equipment

0.08 (0.05–0.10)

5.4

⬍.001

0.10 (0.08–0.11)

12.5

⬍.001

* Corrected for annual (six years) and facility (125 facilities) nesting and adjusted to reflect sample mean values of
respective items for each domain.
†
Effects measure the association between each item on the respective domain score, corrected for annual and
facility nesting and calculated to reflect sample mean values of the respective items for each domain.

delivered in the clinical environments
where they work.
Learning theory and previous studies
suggest that trainees at different levels
may have different learning needs.1 Less
is known about the effects of the learning
environment and its relative contribution
to trainee satisfaction at various levels

616

of medical education. One study in
ambulatory teaching sites demonstrated
that medical students and residents from
five medical schools in Ontario differed
in their perceptions of what enhanced
their ambulatory training experience.1
Rating the importance of “site
characteristics” and “preceptor

behaviors” to their learning, medical
students more highly valued preceptor
interactions (effective teachers, readily
available preceptors, opportunity to
observe preceptor), whereas residents
valued patient mix and practice logistics
(adequate number and variety of
patients, opportunity to see patients

Academic Medicine, Vol. 83, No. 6 / June 2008

Medical Education

independently). This LPS-based
observation suggests that clinical aspects
of the learning environment were more
important to residents. In a recent study
from the United Kingdom,14 medical
students assigned to traditional teaching
hospitals were compared with students at
other types of hospitals. Students were
more satisfied with the teaching at the
traditional hospitals but more satisfied
with the clinical and practical
environment at the nontraditional
hospitals. Specific practice environment
items that were more valued by medical
students included the spectrum of
problems, opportunity for hands-on
experience, and practice of clinical
skills.14 Our analysis of the LPS’s national
sample of trainees suggests that learners
at all levels of medical education placed a
higher value on the learning environment
than on teaching style and behavior. In
VA facilities, although learners’
satisfaction with clinical faculty was very
high, the learning environment, adjusted
at a facility level, contributed most to the
overall training satisfaction score. Prior
work1,14 has a limited and varied
description of learning environment.
The comprehensive development of the
LPS has brought further clarity to the
content of this important domain.
Furthermore, items used to evaluate
the perceptions of the learning
environment domain, as described in
this study, should be taken into
consideration in assessing overall
training satisfaction in other types of
hospitals, settings, and training years.
The results for overall satisfaction as
measured by the LPS showed significant
differences in satisfaction by level of
training. More advanced medical
students were less satisfied than first-year
students, whereas PGY1 through PGY3
residents were less satisfied than more
advanced PGY4 through PGY7 residents.
The overall satisfaction differences by
training year may represent a reflection of
what is known about medical trainee
mood and attitude changes through the
course of their training. Cynicism seems
to increase among medical students,
decline during residency, and reach
its lowest point among attending
physicians.15 Third-year medical students
as well as interns have a loss of idealism
during training.16,17 Attitude and mood
changes affect medical students and
physician residents, with improvements

Academic Medicine, Vol. 83, No. 6 / June 2008

towards the end of their training.18,19
These findings lend face validity to
the LPS overall satisfaction measure
and demonstrate the value of serial
administration of the survey across all
levels of medical training. Further
analysis of these trends and their impacts
on the survey domains and items may
lead to a better understanding of trainees’
perceptions and needs at various levels of
medical education.
Our findings may provide direction to
organizations that are interested in
improving trainee satisfaction. The
VA is an organization with a stated
commitment to the education of health
care professionals, and, as such, it is
invested in making strides in the
improvement in its trainees’ satisfaction.
Improvements in the learning
environment, especially quality of care,
while challenging, are more likely to
result in larger increases in trainee
satisfaction then modifications to the
physical environment (e.g., parking and
food services).
This study has several limitations. The
first limitation was the relatively low
response rate of the LPS. No registry
existed to identify all potential
respondents, so the size of the target
populations can only be estimated. The
limited penetration raises the issue of
sampling bias. Fortunately, from 2002 to
2004, questions identical to those
included in the LPS were included in the
fourth-year medical students’
questionnaire by the Association of
American Medical Colleges (AAMC),
which has a response rate of 97%. The
value of the VA clinical training
experience was rated similarly by fourthyear students in both the AAMC
questionnaire (72%–73% rating of excellent or very good) and LPS (73%–78%
rating of excellent or very good). Thus,
on the basis of a comparison with the
AAMC questionnaire, our findings
indicate that the fourth-year medical
students responding to the LPS were
representative of fourth-year medical
students in general.
A second limitation is that the survey
evaluated the most recent VA clinical
training experience and does not
distinguish between the medical student
training specialty or setting (i.e.,
medicine versus surgery, or outpatient

versus inpatient). Although data are
available for the specific disciplines of
physician resident specialty, we elected to
compare students against the entire pool
of postgraduate trainees rather than
adjust for training program. Important
differences in the perceptions of medical
students in different clinical settings and
physician residents in different specialties
may exist, but these could not be
explored in our present analysis.
Additionally, the data do not permit
analyzing the responses of an individual
respondent over time. Because data were
collected anonymously through annual
surveys, the longitudinal experience of
individuals and the impact of repeat
respondents cannot be determined.
Finally, the LPS data are limited to the
description of associations between the
perceptions of respondents and their
clinical training at a VA medical facility.
Commonalities in the care provided in
VA facilities are an advantage to our
study because they allow comparisons
across training sites; however, the
generalizability of findings related to VA
training to other training sites may be
limited. Nevertheless, one could safely
assume that the same factors which
influence the satisfaction or dissatisfaction
of medical students and residents would be
the same regardless of the clinical setting.
In conclusion, medical students and
resident physicians expressed high levels
of satisfaction with their VA clinical
training, with medical students giving
higher ratings than residents. The factors
contributing to overall satisfaction are
remarkably similar for medical students
and residents. Whereas the clinical
learning environment is the domain most
strongly correlated with the overall
training satisfaction score, the other three
domains— clinical faculty/preceptors,
working environment, and physical
environment—were important,
suggesting that efforts to improve
learners’ satisfaction should incorporate
all aspects of the clinical training
experience. Future work that focuses
interventions on key factors associated
with trainee satisfaction, as described in
this study, is likely to find improvement
in the satisfaction of both medical
students and residents. Finally, while
optimizing trainee satisfaction is
important, understanding the linkage
between satisfaction and competence
warrants further study.

617

Medical Education

Dr. Cannon is associate chief of staff for academic
affiliations, George E. Wahlen VA Medical Center,
Salt Lake City, Utah; and Thomas E. and Rebecca D.
Jeremy Presidential and Endowed Chair for Arthritis
Research, School of Medicine, University of Utah,
Salt Lake City, Utah.
Dr. Keitz is chief, Medical Service, Miami VA
Medical Center, Miami, Florida; and associate dean,
Miller School of Medicine, University of Miami,
Miami, Florida.
Dr. Holland is special assistant for policy and
planning, Office of Academic Affiliations, Veterans
Health Administration, Washington, DC.
Dr. Chang is director, Medical and Dental
Education, Office of Academic Affiliations, Veterans
Health Administration and Washington, DC; and
professor of medicine, University of New Mexico
School of Medicine, Albuquerque, New Mexico.
Dr. Byrne is associate chief of staff for education,
Jerry L. Pettis Memorial VA Medical Center, Loma
Linda VA Healthcare System, Loma Linda, California;
and assistant professor of medicine, School of
Medicine, Loma Linda University, Loma Linda,
California.
Dr. Tomolo is chief of the emergency department,
Louis Stokes Cleveland VA Medical Center,
Cleveland, Ohio; and assistant professor of medicine,
School of Medicine, Case Western Reserve
University, Cleveland, Ohio.
Dr. Aron is associate chief of staff for education,
Louis Stokes Cleveland VA Medical Center,
Cleveland, Ohio; and professor of medicine, School
of Medicine, Case Western Reserve University,
Cleveland, Ohio.
Ms. Wicker is research health science specialist,
Department of Veterans Affairs Medical Center,
Dallas, Texas.
Dr. Kashner is associate director for program
evaluation, Office of Academic Affiliations,
Department of Veterans Affairs, Washington, DC;
and professor, Department of Psychiatry, University
of Texas Southwestern Medical Center at Dallas,
Dallas, Texas.

Acknowledgments
The authors wish to acknowledge the members of
the Learners’ Perceptions Advisory Committee
and the dedicated staff in the Office of Academic
Affiliations that together created and
implemented the VA’s Learners’ Perceptions
Survey. Special thanks go to VA Office of
Academic Affiliations staff members Dilpreet
Singh, MS, MPA, Evert Melander, MBA, David
Bernett, Terry Kruzan, and Ed McKay.
Other members of the Learners’ Perceptions
Working Group: John M. Boyle, PhD, Schulman,

618

Ronca & Bucuvalas, Inc., Silver Spring, Md; C.
Richard Buchanan, DMD, FICD, Department of
Veterans Affairs, Washington, DC, and
University of the Pacific School of Dentistry, San
Francisco, Calif; Christopher T. Clarke, PhD, VA
Medical Center and St. Louis University, St.
Louis, Mo; Stephen J. Dienstfrey, MA, MBA,
Schulman, Ronca & Bucuvalas, Inc., Silver
Spring, Md; Sheila C. Gelman, MD, VA Health
Care System of Ohio, Department of Veterans
Affairs, Cincinnati, Ohio; Stuart C. Gilman, MD,
MPH, Department of Veterans Affairs and Long
Beach Department of Medicine, University of
California, Irvine, Calif; Mark Graber, MD, VA
Medical Center, Northport, NY, and Department
of Medicine, SUNY at Stony Brook, NY; Charles
G. Humble, PhD, Office of Quality Improvement,
Department of Veterans Affairs, Morrisville, NC;
Linda D. Johnson, PhD, RN, Office of Academic
Affiliations, Department of Veterans Affairs,
Washington, DC; Catherine P. Kaminetzky, MD,
MPH, Durham VA Medical Center and
Department of Medicine, Duke University Medical
Center, Durham, NC; Mark Meterko, PhD, VA
HSR&D Management and Decision Research
Center, Boston, Mass; Don D. Mickey, PhD, VA
Medical Center, Durham, NC; Gary Nugent, VA
Medical Center, Omaha, Ne; and Antonette M.
Zeiss, PhD, VA Palo Alto Health Care System, Palo
Alto, Calif.

References
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2 Xu G, Wolfson P, Robeson M, Rodgers JF,
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Bosworth HB, Pincus SH. The Veterans
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6 Ko CY, Escarce JJ, Baker L, Sharp J, Guarino
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Varma R, Tiyagi E, Gupta JK. Determining
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Psychometric properties of an instrument to
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Phy MP, Offord KP, Manning DM, Bundrick
JB, Huddleston JM. Increased faculty
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Asch SM, McGlynn EA, Hogan MM, et al.
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Parry J, Mathers J, Al-Fares A, Mohammad
M, Nandakumar M, Tsivos D. Hostile
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on clinical attachment locations. Med Educ.
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JS, Lamberton HH. The natural history of
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Griffith CH 3rd, Wilson JF. The loss of
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Academic Medicine, Vol. 83, No. 6 / June 2008

Medical Education

Appendix 1
Satisfaction Rating Distribution for Domain Scores and Items by Medical
Students and Physician Residents, from a 2001–2006 Study of Learners’
Satisfaction With Their Veterans Affairs (VA) Training
Medical students
Domain score and item
Learning environment

No.

% VS*

%S
Sat

%
Neither

Physician residents
%S
Dis

%V
Dis

No.

% VS*

%S
Sat

%
Neither

%S
Dis

%V
Dis

6268

40.3

47.9

6.8

3.8

1.2

16048

27.5

50.6

11.7

7.6

2.6

Preparation for future training

6228

48.7

40.0

6.5

3.4

1.3

15806

34.8

46.3

11.2

5.8

2.9

Quality of care

6237

37.3

42.9

7.9

8.6

3.4

16014

29.0

44.0

10.9

10.6

5.5

Time for learning

6237

41.8

43.4

6.9

6.1

1.8

16035

29.5

42.4

11.9

11.1

5.2

Preparation for clinical practice

6226

46.5

41.7

6.9

3.7

1.2

15976

33.8

46.8

10.7

6.7

3.0

Spectrum of patient problems

6235

40.3

40.6

7.9

9.2

2.1

16024

36.0

43.1

10.5

8.3

2.1

Culture of patient safety

6185

39.1

40.2

10.4

7.5

2.8

15754

31.7

40.4

13.6

9.1

5.2

Working with patients

6232

60.4

34.3

2.0

2.5

0.9

15650

45.8

42.3

5.0

4.9

2.1

Teaching conferences

5848

38.0

41.5

11.4

7.1

2.1

15071

28.6

41.9

14.8

9.9

4.8

Degree of autonomy

6217

62.1

31.6

3.3

2.3

0.8

16067

61.1

31.6

4.0

3.1

1.1

Diversity of patients

5890

29.8

37.3

12.8

16.2

3.9

11843

26.7

40.5

15.0

14.0

3.8

Degree of supervision

6247

53.5

38.2

3.9

3.5

0.9

16093

46.1

40.7

6.8

5.4

2.1

Amount of noneducational
work (“scut”)

6061

35.6

36.4

11.9

10.2

5.9

15757

22.8

29.2

12.0

18.6

17.4

...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
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...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................

Interdisciplinary approach

6100

34.7

42.8

15.0

6.1

1.4

15750

26.6

42.2

17.5

10.0

3.7

Access to specialty expertise

6125

35.8

42.0

11.8

8.2

2.2

15925

30.5

42.5

12.1

10.4

4.5

Preparation of business aspects
of clinical practice

5549

18.3

20.9

28.5

22.1

10.3

13316

12.3

21.4

25.3

22.7

18.3

Clinical faculty

6336

52.0

39.0

4.2

3.5

1.4

16020

44.3

42.4

6.3

4.8

2.1

Quality of faculty

5988

53.2

36.6

5.0

3.8

1.5

11969

47.1

39.2

6.7

4.6

2.4

Teaching ability

6328

54.5

37.3

2.6

4.0

1.6

16051

46.2

41.6

4.8

5.2

2.2

Clinical skills

6316

58.6

36.2

2.1

2.2

0.9

15931

50.4

41.0

3.7

3.5

1.4

Evidence-based clinical practice

6216

49.6

37.7

8.3

3.1

1.3

14147

41.4

41.0

9.8

5.1

2.6

Mentoring by faculty

5664

45.0

36.0

11.3

5.8

1.9

11580

40.5

37.8

12.4

6.3

3.1

Role models

6292

49.1

35.4

8.4

4.7

2.3

16005

41.1

38.8

10.9

6.0

3.3

Approachability/openness

6326

56.9

33.3

4.8

3.5

1.6

16068

58.4

31.7

5.3

3.0

1.6

Interest in teaching

6311

56.5

33.2

4.1

4.4

1.9

16048

48.0

37.9

6.2

5.4

2.5

Patient oriented

6313

53.9

35.7

5.3

3.5

1.6

15921

48.0

38.3

7.6

4.2

1.8

Fairness in evaluation

6067

52.8

33.1

7.6

4.5

2.1

15346

48.5

35.5

10.8

3.3

1.9

Accessibility/availability

6292

46.8

39.4

7.3

4.7

1.7

16046

47.6

37.8

7.2

5.3

2.1

Timeliness of feedback

6218

46.6

35.5

9.2

6.4

2.4

15826

42.0

37.3

12.1

5.6

3.0

Research mentoring

3321

28.4

25.1

36.3

6.0

4.2

8313

24.5

28.6

30.7

9.3

7.0

6151

33.5

50.1

10.0

5.3

1.2

15918

23.6

47.0

15.7

10.4

3.4

Workspace

6002

40.1

37.0

8.5

11.1

3.3

15901

36.8

38.2

9.7

10.5

4.7

Peer group morale

6056

41.4

43.8

8.0

5.2

1.7

15785

30.6

44.1

12.0

9.8

3.5

Working environment

Faculty/preceptor morale

6149

47.5

40.2

5.4

5.3

1.6

15977

39.7

43.3

7.1

7.2

2.7

Computerized Patient Record
System (CPRS)

5978

70.7

23.2

3.1

2.2

0.9

15917

58.5

28.8

5.1

4.7

2.9

Ancillary/support staff morale

6105

27.4

33.4

9.4

18.2

11.6

15957

19.9

32.2

11.5

20.5

Computer access

5945

51.5

34.0

5.9

6.0

2.5

15920

47.6

35.8

7.2

6.3

3.2

Laboratory services

5543

29.6

39.6

13.6

13.3

4.0

15385

22.9

38.8

13.8

16.6

7.9

Radiology services

5500

30.2

38.5

13.4

12.7

5.3

15074

20.8

36.1

13.5

18.1

11.5

Internet access

5863

47.4

32.4

6.8

8.6

4.8

15777

42.5

33.4

7.5

9.8

6.8

Ancillary/support staff

5895

26.0

34.9

12.1

16.2

10.8

15728

17.9

32.2

13.9

19.4

16.6

15.9

Orientation program

5679

38.2

39.5

13.6

6.5

2.1

14747

28.7

38.4

20.9

7.5

4.6

Library services

4514

33.8

32.8

23.8

6.8

2.9

13267

27.0

34.4

24.0

9.2

5.4

Call schedule

5092

41.9

41.2

12.7

3.2

1.0

14191

36.0

42.3

14.2
5.1
2.4
(Appendix continues)

Academic Medicine, Vol. 83, No. 6 / June 2008

619

Medical Education

Appendix 1 (continued)
Medical students

Physician residents

% VS*

%S
Sat

%
Neither

%S
Dis

%V
Dis

5936

32.6

46.8

12.3

7.0

1.1

Facility maintenance upkeep

5863

39.5

39.7

10.2

8.7

Facility cleanliness/
housekeeping

5927

41.1

39.2

9.2

8.4

Call rooms

4176

39.7

32.6

11.2

10.5

6.1

11236

26.6

34.3

14.0

14.4

10.7

Availability of food at medical
center when on call

4903

21.0

21.7

8.7

21.1

27.5

12608

11.5

17.3

9.8

20.6

40.8

Domain score and item
Physical environment

No.

% VS*

%S
Sat

%
Neither

%S
Dis

%V
Dis

15612

23.6

45.9

17.6

10.4

2.4

1.9

15617

31.5

42.0

13.7

9.3

3.4

2.1

15698

33.9

40.0

11.7

10.0

4.4

No.

Heating and air conditioning

5923

43.0

38.8

7.7

7.5

3.1

15664

35.9

40.3

10.9

8.6

4.2

Lighting

5917

44.5

38.5

7.6

7.7

1.8

15657

38.5

42.4

11.2

5.9

2.0

Availability of needed
equipment

5780

34.9

42.6

10.3

10.4

1.9

15602

27.2

40.5

12.6

14.7

5.0

Maintenance of equipment

5664

34.9

42.3

11.8

9.1

1.9

15470

26.4

40.8

15.1

13.0

4.7

Convenience of facility location

5947

59.4

31.4

3.9

4.0

1.4

15718

50.8

35.1

6.9

4.7

2.4

Personal safety

5935

52.7

34.5

6.2

5.3

1.3

15689

45.2

37.4

8.9

6.0

2.4

Parking

5565

40.5

29.0

6.1

13.1

11.2

14704

32.4

30.9

8.3

14.4

14.0

Availability of phones

5816

50.4

36.3

6.8

5.6

0.9

15697

45.5

38.3

7.2

6.9

2.1

* VS, very satisfied; S Sat, somewhat satisfied; S Dis, somewhat dissatisfied; V Dis, very dissatisfied.

620

Academic Medicine, Vol. 83, No. 6 / June 2008

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