Kaminetzky_Keitz_Kashner_LPS subspecialty fellows (TOC)

Terms of Clearance: Learner’s Perception Survey, 2900-0691
Kaminetzky, Keitz, Kashner, LPS Subspecialty
Fellows
Training Satisfaction for Subspecialty Fellows in
Internal Medicine: Findings from the Veterans
Affairs (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.

Kaminetzky et al. BMC Medical Education 2011, 11:21
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RESEARCH ARTICLE

Open Access

Training satisfaction for subspecialty fellows in
internal medicine: Findings from the Veterans
Affairs (VA) Learners’ Perceptions Survey
Catherine P Kaminetzky1,2*†, Sheri A Keitz3,4†, T Michael Kashner5,6†, David C Aron7,8†, John M Byrne6,9†,
Barbara K Chang5†, Christopher Clarke5†, Stuart C Gilman5†, Gloria J Holland5†, Annie Wicker5,10† and
Grant W Cannon11,12†

Abstract
Background: Learner satisfaction assessment is critical in the design and improvement of training programs.
However, little is known about what influences satisfaction and whether trainee specialty is correlated. A national
comparison of satisfaction among internal medicine subspecialty fellows in the Department of Veterans Affairs (VA)
provides a unique opportunity to examine educational factors associated with learner satisfaction. We compared
satisfaction across internal medicine fellows by subspecialty and compared factors associated with satisfaction
between procedural versus non-procedural subspecialty fellows, using data from the Learners’ Perceptions Survey
(LPS), a validated survey tool.
Methods: We surveyed 2,221 internal medicine subspecialty fellows rotating through VA between 2001 and 2008.
Learners rated their overall training satisfaction on a 100-point scale, and on a five-point Likert scale ranked
satisfaction with items within six educational domains: learning, clinical, working and physical environments;
personal experience; and clinical faculty/preceptor.
Results: Procedural and non-procedural fellows reported similar overall satisfaction scores (81.2 and 81.6). Nonprocedural fellows reported higher satisfaction with 79 of 81 items within the 6 domains and with the domain of
physical environment (4.06 vs. 3.85, p <0.001). Satisfaction with clinical faculty/preceptor and personal experience
had the strongest impact on overall satisfaction for both. Procedural fellows reported lower satisfaction with
physical environment.
Conclusions: Internal medicine fellows are highly satisfied with their VA training. Nonprocedural fellows reported
higher satisfaction with most items. For both procedural and non-procedural fellows, clinical faculty/preceptor and
personal experience have the strongest impact on overall satisfaction.

Background
The quality of training provided in physician training
programs is an important focus of health systems, hospitals and undergraduate and graduate medical education
leaders. Trainee satisfaction is one element of quality in
clinical education. Its relationship with different components of clinical, learning and work experiences is often
explored to identify elements associated with high
* Correspondence: [email protected]
† Contributed equally
1
Department of Medicine, Duke University, Durham NC, USA
Full list of author information is available at the end of the article

satisfaction within individual training programs, but not
across training programs nationally or across disciplines.
Understanding which factors contribute to trainee satisfaction, and how they contribute, is critical to the design
of education programs that will meet the needs of trainees across different specialties.
An ideal setting for examining components of trainee
satisfaction is the Department of Veterans Affairs (VA).
VA is the second largest funding source of United States
(US) physician training positions, with over 9500 physician resident positions of which 1600 internal medicine
subspecialty fellow positions were funded in 2008-2009.

© 2011 Kaminetzky et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

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Each year, nearly one-third of the nation’s physician
trainees rotate at 120 VA centers and three independent
outpatient clinics through affiliations with medical
schools and teaching hospitals.
Previous studies of satisfaction with VA training have
used data from the Learners’ Perceptions Survey (LPS), a
validated survey instrument that measures satisfaction
across multiple domains. Since 2001, VA has administered the LPS annually to all learners who train at VA
medical facilities. Prior work using data from the LPS
established differences in perception of satisfaction for
learners in different stages of training [1] and between
physician trainees in different specialties [2]. One hypothesis to explain differences between types of trainees is
that such variability may be related to differences in daily
experiences. To test this hypothesis, we examined the
degree to which predominance of procedural experiences
explain dissimilarities among learners, focusing on fellows in different subspecialties in internal medicine.
Specifically, we measured satisfaction across internal
medicine fellows by subspecialty and compared satisfaction between procedural versus non-procedural subspecialties. We also identified factors associated with
satisfaction and compared how these factors differ
between fellows in these two groups.

Methods
Survey development

The LPS was developed to examine and measure learner
satisfaction for all healthcare trainees working in VA.
Survey development began in 1999 using standard psychometric procedures [2]. An initial item pool was
derived based on an exhaustive review of the literature
on learner satisfaction and refined based on feedback
from 15 focus groups of VA faculty and clinical trainees.
Items were grouped into six domains: clinical faculty or
preceptor (13 items), learning environment (15), clinical
environment (15), working environment (13), physical
environment (12) and personal experience (13). For each
item, respondents were asked to rate satisfaction with
VA training using a five-point Likert scale. The survey
was piloted on over 1,000 trainees from 22 geographically
diverse VA medical centers. Confirmatory factor analysis
upheld the integrity of each domain. On the basis of pilot
testing, the survey was refined to items that contributed
to an overall training satisfaction and to satisfaction ratings in six educational domains. Items and the corresponding domains are listed in Additional file 1.
Since its 2001 rollout, the LPS has been administered
annually to assess perceptions of clinical learners toward
their VA experiences. The LPS consistently shows
domain content stability, integrity and Alpha reliability
in the .90s for both the overall survey and its subdomains [2].

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Over time, 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 evaluated only those components of the survey that have been unchanged since 2001, including
scores for overall training satisfaction, educational
domains and their associated items.
LPS Outcome Measures

To derive an overall satisfaction score, learners are
asked: “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 response to this question is the “overall training satisfaction score” and the primary outcome
measure used in this analysis.
Study design

The current report presents survey results from an
eight-year summary analysis of trainees’ satisfaction with
training experiences at VA medical centers from 2001
through 2008.
Study population and survey administration

Participants were physician fellows in internal medicine
fellowships who rotated through a VA facility during the
academic year. In 2001, trainees registered for the LPS survey through a post-card registration process. Registered
trainees were then mailed a paper survey or could complete an online version of the survey. For subsequent years
the separate registration process was discontinued, and all
physician trainees were encouraged 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 Office of Academic
Affiliations to all physician trainees for whom addresses
were available. 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 exclusively online.
We categorized fellows in internal medicine-based
programs as participating in procedural fellowship (cardiology, gastroenterology and pulmonary/critical care
medicine) or non-procedural fellowships (endocrinology,
geriatrics, hematology/oncology, infectious diseases,
nephrology and rheumatology).
Analyses

We used mixed-effects models to adjust scores by subspecialty and to compute both the effect of individual
items on domain scores and the effect of domain scores

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on overall satisfaction for the VA hospital. We adjusted
all estimates to account for each subspecialty, calculated
to reflect a PGY-4 fellow, and corrected for year of survey
and facility nesting. Adjustment was necessary to permit
comparisons across subspecialties when responders may
be distributed across survey year and facilities differently.
No adjustments were made to reflect characteristics of
individual responders because the information was limited due to individual responder anonymity. Furthermore,
we wanted to measure total, rather than partial, differences across specialties. We computed item effect sizes
from the estimated coefficients to mean-centered domain
item × subspecialty indicator interaction terms. Domain
and domain items were scaled between one and five,
where five indicates very satisfied, and one indicates very
dissatisfied. We measured effect sizes (item on domain
scores) to reflect the increase in domain score per unit
increase in item score. Effect sizes were adjusted to
reflect a PGY-4 and corrected for year of survey and
facility nesting. We did not adjust to reflect changes in
the other items since our purpose was to compute a total
effect size. All procedures were performed using SPSS.
To account for multiple comparisons, we consider statistically significant only factors where p ≤ 0.001.

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Table 1 Number of responders by year of survey, level of
training and discipline
Responses

No. (% of Total)

Year of Survey
2001

141 (6.4%)

2002

184 (8.3%)

2003

309 (13.9%)

2004

260 (11.7%)

2005

264 (11.9%)

2006

368 (16.6%)

2007

268 (12.1%)

2008

427 (19.2%)

Total

2221 (100%)

Post graduate year
PGY-4

976 (43.9%)

PGY-5

671 (30.2%)

PGY-6

440 (19.8%)

PGY-7 and above
Total

134 (6.0%)
2221 (100%)

Procedural group
Cardiology

459 (20.7%)

Ethical considerations

Gastroenterology

269 (12.1%)

The U.S. Office of Management and Budget, which
reviews and approves federal government sponsored surveys, approved the LPS. We maintained confidentiality
by keeping respondent information in a separate database and reviewing only aggregate data. Participation in
the survey was voluntary. The confidential nature of the
data collection and voluntary participation were fully
disclosed to survey participants.

Pulmonary

298 (13.4%)

Subtotal

1026 (46.2%)

Non-procedural group
Endocrinology

155 (7.0%)

Geriatrics

264 (11.9%)

Hematology/Oncology

283 (12.7%)

Infectious Diseases

193 (8.7%)

Results

Nephrology

191 (8.6%)

Overall training satisfaction

Rheumatology

There were 2,221 responses by fellows between 2001
and 2008 (Table 1). The distribution of respondents by
fellowship was very similar to the distribution of funded
positions by the OAA for each fellowship type (data not
shown). There were 1,026 responses in the procedural
group and 1,195 responses in the non-procedural group.
Cardiology fellows provided the largest number of
responses for procedural fellows (n = 459), and Hematology-Oncology fellows provided the largest number of
responses for non-procedural fellows (n = 283).
Overall satisfaction scores were similar for all internal
medicine subspecialties, revealing only minor differences
in adjusted mean scores that did not achieve statistical
significance (Table 2). Additionally, the mean adjusted
overall satisfaction scores for procedural fellows (81.2)
and non-procedural fellows (81.6) were not statistically
significantly different (p = 0.59).

Subtotal
Total

109 (4.9%)
1195 (53.8%)
2221 (100%)

Satisfaction at the domain level

Procedural and non-procedural fellows reported similar
satisfaction with the following domains: clinical
faculty/preceptors, personal experiences, learning,
working and clinical environments. There were differences in the reported satisfaction with overall physical
environment, with non-procedural fellows reporting
higher satisfaction compared to procedural fellows
(4.06 vs. 3.85, p < 0.001) (Table 3). Rank order of
domain satisfaction was similar for procedural and
non-procedural fellows, with trainees reporting highest

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Table 2 Adjusted overall training satisfaction scores for
resident fellows by subspecialty
Discipline

Adjusted overall score*
(95% CI)

Procedural
Cardiology
Gastroenterology

80.8 (79.3, 82.4)
83.6 (81.8, 85.4)

Pulmonary

79.5 (77.7, 81.2)

Subtotal

81.2 (79.0, 83.4)

Non-procedural
Endocrinology

80.2 (78.0, 82.4)

Geriatric

83.8 (82.1, 85.4)

Hematology/Oncology
Infectious Diseases

79.8 (78.1, 81.5)
81.9 (79.8, 83.9)

Nephrology

80.5 (78.6, 82.5)

Rheumatology

84.2 (81.6, 86.6)

Subtotal

81.6 (80.6, 82.5)

* Scores range from 1 to 100, where 100 indicates very satisfied with overall
training at VA, and are adjusted to reflect mean by subspecialty, calculated for
PGY-4, and corrected for year of survey and facility nesting.

satisfaction with clinical faculty/preceptors, followed by
personal experience, learning environment and working environment.
To measure the impact of domains on overall satisfaction, we measured the effect of domains on overall satisfaction score as the change in overall satisfaction (range
1 to 100) associated with each one-point change in the
mean scale score for the domain (Likert scale with
range 1 to 5). Each domain provided a statistically significant contribution to the overall score for both procedural and non-procedural trainees (data not shown). A
comparison of the impact of each domain on overall
satisfaction revealed differences between procedural and
non-procedural fellows, with learning environment and
personal experience contributing more to overall satisfaction for procedural fellows than for non-procedural
fellows (Table 4). However, the rank order of the impact
of each domain on overall satisfaction was similar, with
both procedural and non-procedural trainees ranking
personal experience the highest, followed by learning
environment.

Table 3 Adjusted mean scores for domains and selected* items for non-procedural and procedural fellows
Non-procedural fellows

Procedural fellows

Mean (95% CI)**

Mean (95% CI)

t

p

4.42 (4.36, 4.48)

4.32 (4.25, 4.40)

2.41

0.016

Accessibility/availability

4.48 (4.43, 4.54)

4.35 (4.28, 4.42)

3.35

0.001

Timeliness of feedback
Fairness in evaluation

4.33 (4.27, 4.40)
4.46 (4.40, 4.52)

4.19 (4.11, 4.27)
4.31 (4.24, 4.38)

3.30
3.66

0.001
<0.001

Patient-oriented

4.50 (4.44, 4.56)

4.37 (4.30, 4.44)

3.29

0.001

Personal experience

4.35 (4.29, 4.41)

4.24 (4.17, 4.31)

2.83

0.005

4.25 (4.17, 4.33)

4.07 (3.98, 4.17)

3.38

0.001

4.17 (4.10, 4.24)

4.11 (4.03, 4.19)

1.35

0.18

4.19 (4.11, 4.26)
4.02 (3.94, 4.10)

3.99 (3.90, 4.08)
3.84 (3.75, 3.94)

4.05
3.23

<0.001
0.001

Category
Clinical faculty/preceptors

Continuity of relationship with patients
Learning environment
Time for learning
Teaching conferences
Working environment

4.12 (4.04, 4.19)

4.00 (3.91, 4.08)

2.40

0.017

Ancillary/support staff morale

3.84 (3.74, 3.94)

3.54 (3.42, 3.66)

4.59

<0.001

Laboratory services

3.99 (3.91, 4.07)

3.81 (3.71, 3.91)

3.38

0.001

Ancillary/support staff

3.74 (3.63, 3.84)

3.52 (3.40, 3.64)

3.38

0.001

Physical environment
Maintenance of equipment

4.06 (3.99, 4.14)
4.05 (3.97, 4.14)

3.85 (3.76, 3.94)
3.87 (3.77, 3.96)

4.48
3.50

<0.001
0.001

2.82 (2.68, 2.96)

2.45 (3.30, 2.61)

4.16

<0.001

4.00 (3.91, 4.09)

3.92 (3.82, 4.02)

1.36

0.18

Availability of food on call
Clinical environment

* Items presented if statistically significant differences between non-procedural and procedural fellow reached p ≤ 0.001. All domains or items are presented in
Additional file 1.
** Mean score scaled from 1 to 5, where 5 indicated very satisfied and 1 indicates very dissatisfied. Scores are adjusted to reflect a mean respondent by
subspecialty grouping (procedure vs. non-procedural), computed for a PGY-4, and corrected for year of survey and facility nesting.

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Table 4 Adjusted effects of each domain score on overall satisfaction for non-procedural and procedural fellows
Non-procedural fellows

Procedural fellows

Mean (95% CI)*

Mean (95% CI)

t

p

Clinical faculty/preceptors

6.61 (5.81, 7.41)

7.86 (7.07, 8.65)

2.2

0.03

Personal experience

8.93 (8.06, 9.79)

11.34 (10.48, 12.20)

3.9

<0.001

Learning environment

7.83 (7.16, 8.50)

9.53 (8.81, 10.24)

3.4

0.001

Working environment

6.95 (6.24, 7.66)

7.60 (6.87, 8.34)

1.3

0.21

Physical environment

5.12 (4.32, 5.92)

5.98 (5.21, 6.74)

1.5

0.13

Clinical environment

7.24 (6.52, 7.95)

7.29 (6.56, 8.01)

0.1

0.92

Category

*Effect size is the increase in overall satisfaction, measured on a 100-point scale, per increase in domain score, measured on a 5-point scale. Effect sizes were
adjusted to reflect mean respondent by subspecialty grouping (procedural vs. non-procedural), computed for a PGY-4, and corrected for year of survey and
facility nesting.

Satisfaction with items within domains

Results for non-procedural fellows showed a consistent
pattern of greater satisfaction on individual items, both
in number of items and in magnitude (Additional file 1).
Non-procedural fellows reported significantly higher
satisfaction with: accessibility and availability of clinical
faculty and preceptors; timeliness of feedback; fairness
in evaluation; clinical faculty and preceptors’ patientoriented nature; time for learning; teaching conferences;
morale of ancillary and support staff; laboratory services;
ancillary and support staff; maintenance of equipment;
availability of food on call; and continuity of relationship
with patients (Additional file 1). Procedural fellows
reported higher satisfaction with only two of 81 items
(timely performance of necessary procedures/surgeries
and degree of autonomy); these differences did not
achieve statistical significance.
Within the domain of clinical faculty and preceptor,
the rank order of satisfaction with items was similar,
with highest satisfaction reported for approachability
and openness, clinical skills, patient-oriented, and quality of faculty. For the domain of personal experience,
the rank order of satisfaction with items was also similar, with highest satisfaction reported for relationship
with patients, appreciation of respondent’s work by
patients, personal reward and personal responsibility for
patient care.
We calculated the contribution of each item to its
domain satisfaction score, measuring the change in the
respective domain score associated with each one-point
change on the Likert scale for individual items. Those
items with larger effect sizes are listed in Table 5 and a
more comprehensive listing is found in Additional file 2.
For both types of trainees, most items within clinical
faculty/preceptors were strongly associated with domain
satisfaction, as were many items within the domain of personal experience. All items were found to have a statistically significant association with the respective domain
score, both for procedural and non-procedural fellows
(Additional file 2). Only a few items had statistically

significant differences in impact on satisfaction for the two
types of fellows (Additional file 2). Cleanliness of facilities
and housekeeping, balance of personal and professional
life, parking and level of job stress contributed more
strongly to overall satisfaction for procedural fellows; however, these items contributed only modestly to the overall
score and many were associated with lower overall domain
satisfaction scores.

Discussion
Our study is the first to comprehensively survey internal
medicine subspecialty fellow satisfaction across multiple
programs and compare perceptions between procedural
and non-procedural fellows. Overall satisfaction with
VA training is similar between procedural and non-procedural fellows in internal medicine, but differences
exist at the item and domain-level.
The LPS is a validated survey instrument with robust
psychometric properties and content and face validity
that has been used to evaluate trainee satisfaction across
a large, relatively uniform healthcare system. Previous
studies have demonstrated its usefulness in comparing
trainee perceptions across disciplines. Keitz et al found
that the LPS functioned well in discriminating differences
between different types of learners in VA [2]. Cannon et
al extended the scope of the LPS by comparing satisfaction between medical students and residents [1]. Analysis
of differences in subspecialty fellow satisfaction provides
valuable information to GME leaders for program development and extends the utility of the LPS for evaluating
satisfaction in graduate medical education.
There were similarities between our findings and
those of Keitz et al [2] and Cannon et al [1] with respect
to overall satisfaction and domain satisfaction. Overall
satisfaction was similar for fellows, different types of
residents [1,2] and medical students [1]. With the exception of physical environment, procedural and non-procedural fellows had similar domain satisfaction, as was
seen with both medical students and residents [1]. Like
medical students [1] and residents [1,2], fellows reported

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Table 5 Domain items with the largest* adjusted effect sizes on domain scores
Category

Non-procedural fellows

Procedural fellows

adj. effect (95% CI)

adj. effect (95% CI)

t

p

Clinical faculty/preceptors
Clinical skills**

0.88 (0.84, 0.92)

0.88 (0.84, 0.93)

0.1

0.90

Teaching ability

0.84 (0.80, 0.87)

0.83 (0.79, 0.86)

0.4

0.67

Interest in teaching

0.76 (0.73, 0.80)

0.76 (0.73, 0.79)

0.1

0.92

Accessibility/availability

0.69 (0.64, 0.73)

0.71 (0.67, 0.75)

0.8

0.45

Approachability/openness

0.81 (0.76, 0.86)

0.78 (0.73, 0.82)

0.9

0.38

Fairness in evaluation
Role models

0.72 (0.68, 0.77)
0.75 (0.72, 0.77)

0.74 (0.70, 0.78)
0.75 (0.73, 0.78)

0.6
0.4

0.53
0.67

Patient-oriented

0.86 (0.82, 0.90)

0.80 (0.76, 0.84)

0.4

0.02

Quality of faculty

0.87 (0.83, 0.90)

0.83 (0.80, 0.87)

1.3

0.19

Evidence-based clinical practice

0.78 (0.74, 0.82)

0.84 (0.80, 0.88)

2.2

0.03

Learning environment
Working with patients

0.71 (0.66, 0.76)

0.70 (0.65, 0.76)

0.1

0.90

Preparation for clinical practice
Preparation for future training

0.69 (0.65, 0.73)
0.72 (0.68, 0.76)

0.72 (0.68, 0.76)
0.75 (0.71, 0.79)

0.9
1.0

0.38
0.31

0.76 (0.73, 0.79)

0.76 (0.73, 0.79)

0.1

0.92

Clinical environment
Ability to get the best care for patients
Physical environment
Facility maintenance/upkeep

0.67 (0.63, 0.71)

0.70 (0.66, 0.74)

1.0

0.31

Lighting
Facility cleanliness/housekeeping

0.73 (0.68, 0.78)
0.63 (0.59, 0.67)

0.72 (0.67, 0.77)
0.73 (0.69, 0.77)

0.3
3.6

0.79
<0.001

Personal experience
Relationship with patients

0.75 (0.68, 0.81)

0.75 (0.68, 0.81)

0.1

0.99

Enjoyment of respondent’s work

0.73 (0.69, 0.77)

0.81 (0.77, 0.85)

2.9

0.004

Personal responsibility for patients

0.62 (0.57, 0.66)

0.71 (0.66, 0.76)

2.7

0.008

Enhancement of clinical knowledge/skills

0.78 (0.74, 0.81)

0.83 (0.79, 0.86)

2.0

0.05

*Items presented if the adjusted effect size for either non-procedural or procedural fellows was > = 0.70. Additional file 2 provides adjusted effect sizes for all
LPS items.
**Effect size equals the change in the domain score per unit increase in the item score, adjusted to reflect a mean respondent by subspecialty grouping
(procedural vs. non-procedural), computed for a PGY-4, and corrected for year of survey and facility nesting.

highest satisfaction with the domain of clinical faculty
and preceptors. All three studies found that learning
environment contributed highly to overall satisfaction,
although in our study this was more so for procedural
fellows. Unlike in the previous studies utilizing the LPS,
our study examined the personal experience domain
and found that personal experience was the domain
most strongly associated with overall satisfaction for
both procedural and non-procedural fellows, with both
reporting similarly high levels of satisfaction with relationship with patients, appreciation of respondent’s
work by patients, personal reward and personal responsibility for patient care.
While domain satisfaction was similar across a wide
spectrum of learners in all three studies, individual
items within domains and their contribution to overall

domain score provided more distinction between different types of learners. For example, procedural fellows
reported lower satisfaction with several items in the
clinical faculty/preceptor domain including accessibility/
availability, timeliness of feedback, fairness of evaluation
and patient orientation. Keitz et al found similar results
for surgical residents who reported lower satisfaction
with accessibility and availability of faculty and preceptors as compared to less procedural residents [2]. For
subspecialty fellows, item differences were seen in
equipment maintenance and food on-call, with procedural fellows expressing lower satisfaction. These results
may reflect differing needs of procedural fellows who
use diagnostic and therapeutic equipment more frequently and may be more likely to be on-call overnight
in the hospital.

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Within the working environment, non-procedural fellows reported higher satisfaction with ancillary/support
staff morale, laboratory services, and ancillary/support
staff. In a previous study, differences were also found
between medical students and residents [1], and among
residents, with internal medicine residents least satisfied
with these items [2]. The relatively lower levels of satisfaction with these items among procedural fellows and
internal medicine residents may reflect higher intensity
of interactions with these services and therefore a different level of expectation compared to other types of learners. Whereas past studies suggested that such
differences in satisfaction may be related to the differences in types of training programs [2], current results
showing differences between procedural and non-procedural fellows may reflect degrees to which the same
parts of the VA healthcare system intersect differently
with the training goals of different program types and
available training infrastructure.
Levels of satisfaction may reflect those attitudes and
values that influenced physicians’ choice of specialty
training. A number of studies have evaluated predictors
of subspecialty choice among residents and satisfaction
with career choice among practicing physicians. In a
study of factors associated with subspecialty choice of
Canadian internal medicine residents, Horn et al found
that residents pursuing non-procedural fellowships were
more concerned with issues related to lifestyle, stress,
work hours, leisure hours, and patient populations than
those pursuing procedural fellowships [3]. Other studies
have found that lifestyle [4-7], mentorship [3], faculty
influence [4,5,8], role models [3,9,10], resident clinical
experience [3-5,8] and high sense of satisfaction of fellows [8] are important factors in trainee selection of
specialty training. Our study showed that personal
experience (including lifestyle, stress and fatigue) and
clinical faculty/preceptors (including mentoring and role
models) contributed most significantly to overall satisfaction for both types of trainees, suggesting that
improvements in these areas could lead to higher learner satisfaction and possibly more successful recruitment. Furthermore, differences in satisfaction with
career choice have been noted between primary care
and specialty residents [11] as well as procedure and
non-procedure-based practicing physicians [12], suggesting that data on fellow satisfaction may provide useful
information for residents in guiding career choices.
Quality in graduate medical education programs is
complex and has many crucial components such as curriculum, trainee competency, and faculty development.
Learner satisfaction with training is another crucial
component for individual training programs [13], hospital systems [14], and national organizations [15]. With
significant national focus on both changes in health care

Page 7 of 9

systems and regulatory requirements, particularly given
forthcoming changes in Accreditation Council of Graduate Medical Education’s Common Program Requirements, careful analysis of trainees’ satisfaction with
educational and work environments is essential to
improving quality. Byrne et al advocated for the use of a
comprehensive survey tool to examine residents’ satisfaction with training, and demonstrated the use of such
a tool to effect improvements within affiliated hospitals
from one GME program [14]. The authors argued for
the importance of a national, comprehensive survey tool
to monitor trainee experience with the expressed goal of
improving the training environment. In addition, monitoring the experience of trainees may provide advantages to individual programs in the form of longer
accreditation cycle length [16]. Changes in trainee satisfaction should be monitored over time, and ideally both
aggregate and facility-level data would be available to
allow for analysis of variation between facilities.
Our study has several strengths. First, the LPS is a
validated, comprehensive survey tool, providing key
information regarding the work and learning environments in which the majority of physicians train. Second,
the LPS targets learners within one large healthcare system, potentially limiting the degree to which the differences between healthcare systems in which trainees
learn may affect the measured outcomes. Third, the LPS
is designed to assess trainee perceptions across a full
complement of subspecialty training programs, program
training years and academic years. Finally, the results of
this study are likely representative of fellow perceptions
throughout the VA, since the distribution of respondents across subspecialties was nearly identical to the
distribution of VA funded positions nationally for each
subspecialty.
The study has several limitations. First, there were
multiple comparisons performed in this study, which
may have led to statistical error. For this reason, we set
a threshold for statistical significance at p ≤ 0.001. Secondly, because the data are collected anonymously, we
were unable to evaluate the changes in individual
respondents over time, limiting the precision of our
results. Thirdly, we were unable to determine the total
number of fellows within the system and made the survey available but did not distribute the survey to them
directly. Consequently, the estimated response rate was
relatively low, and this strategy could result in selection
bias. However, as mentioned, the distribution of fellow
respondents mirrors the distribution of VA funding for
each specialty. In addition, a comparison of common
questions on the LPS and the American Academy of
Medical Colleges (AAMC) medical student survey,
which has a greater than 90% response rate, have
demonstrated similar results suggesting that the

Kaminetzky et al. BMC Medical Education 2011, 11:21
http://www.biomedcentral.com/1472-6920/11/21

sampling method for the LPS may not be subject to
major selection bias. Finally, we collected the LPS data
only for VA experiences, which may limit the applicability of the findings to other training settings. While most
physicians train in a VA setting, further information
about non-VA training settings would allow better
understanding of how VA experience compares to the
other sites where fellows train.

Conclusions
VA internal medicine fellows of all subspecialties are
generally satisfied with their VA training. For procedural
and non-procedural fellows, satisfaction with the
domains of clinical faculty and preceptors and personal
experience contributed highly to the overall satisfaction
score. Differences in satisfaction were evident in the
comparison, and further study is needed to clarify
whether the sources of these differences arise from dissimilarities in the learners themselves, the training needs
of various disciplines or the parts of the healthcare system or infrastructure with which trainees interact. Better
understanding of the factors associated with satisfaction
among different types of fellows may assist residents in
selecting training programs and may assist program
directors and GME leaders in improving programs,
thereby enhancing recruitment, improving fellow satisfaction with their training experience and enhancing
educational outcomes.
Additional material
Additional file 1: Adjusted mean satisfaction scores for procedural
and non-procedural fellows. This table shows satisfaction with items
within domains, comparing procedural and non-procedural fellows, and
it includes all items examined in this study.
Additional file 2: Adjusted effect size of domain items on domain
scores. This table shows the adjusted effect sizes of all domain items on
domain scores for procedural and non-procedural fellows and compares
the effect size for both types of trainees.

Acknowledgements
This study was funded in part by the Department of Veterans Affairs Office
of Academic Affiliations, Health Services Research and Development Service
(SHP #08-164). Statistical methods were developed in part by the Small
Business Innovation Research (SBIR) program from the National Cancer
Institute (NCI) (R44CA139607).
All statements and descriptions expressed herein do not necessarily reflect
the opinions or positions of the Department of Veterans Affairs or the
National Institutes of Health of the Department of Health and Human
Services.
Author details
Department of Medicine, Duke University, Durham NC, USA. 2Department
of Education, Durham VA Medical Center, Durham NC, USA. 3Department of
Medicine, Miami VA Health Care System, Miami FL, USA. 4Department of
Medicine, University of Miami Miller School of Medicine, Miami FL, USA.
5
Office of Academic Affiliations, Veterans Health Administration, Washington
DC, USA. 6Department of Medicine, Loma Linda University School of
1

Page 8 of 9

Medicine, Loma Linda CA, USA. 7Education Office, Louis Stokes Cleveland
Department of Veterans Affairs Medical Center, Cleveland OH, USA.
8
Department of Medicine, Case Western Reserve University School of
Medicine, Cleveland, OH, USA. 9Department of Education, Loma Linda VA
Medical Center, Loma Linda CA, USA. 10Center for Advanced Statistics in
Education, Loma Linda VA Health Care System, Loma Linda CA, USA.
11
Department of Education, George E. Wahlen VA Medical Center, Salt Lake
City, UT, USA. 12Division of Rheumatology, University of Utah School of
Medicine, Salt Lake City UT, USA.
Authors’ contributions
Authors CPK, SAK, TMK, DCA, JMB, BKC, GJH, and GWC all contributed to the
design of the study, data collection, data collection assessment and
evaluation, data analyses design and data analyses implementation, and
drafting of the manuscript. Author CC contributed to data collection, data
analysis and drafting of the manuscript. Author SCG contributed to data
analysis and drafting of the manuscript. Author AW contributed to data
analyses design and implementation, and drafting of the manuscript. All
authors have read and provided approval to the manuscript as submitted.
Competing interests
The authors declare that they have no competing interests.
Received: 21 September 2010 Accepted: 17 May 2011
Published: 17 May 2011
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1472-6920/11/21/prepub
doi:10.1186/1472-6920-11-21
Cite this article as: Kaminetzky et al.: Training satisfaction for
subspecialty fellows in internal medicine: Findings from the Veterans
Affairs (VA) Learners’ Perceptions Survey. BMC Medical Education 2011
11:21.

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