An analysis of the Educational Environment at the Malta Foundation Programme&nbsp;using the Postgraduate Hospital Educational Environment Measure (PHEEM).

doi:10.21203/rs.3.rs-120405/v1

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Research Article

An analysis of the Educational Environment at the Malta Foundation Programme using the Postgraduate Hospital Educational Environment Measure (PHEEM).

https://doi.org/10.21203/rs.3.rs-120405/v1

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posted 15 Dec, 2020

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Background Learning from managing patients in a real-world context is by far superior to simulation learning. A substandard educational environment is associated with poor patient care and suboptimal learning outcomes. The measurement of the educational environment provides an insight on what is needed to improve the level of training.

Methods This study used the Postgraduate Hospital Educational Environment Measure (PHEEM) to measure the educational environment at the Malta Foundation Programme. Descriptive statistics were used to describe the demographics of the study population. Non-parametric comparative statistics were used to identify statistically significant differences between groups.

Results 98 trainees out of 370 (26.5%) completed the online questionnaire. These consisted of 39 FY1s (31.5% of 124), 33 FY2s (24.8% of 133) and 26 Extended FYs (23.0% of 113). The 40-item PHEEM showed good reliability with a Cronbach’s α value of 0.912. These doctors have perceived their educational environment as more positive than negative. There seems to be a dip midway through training with an improvement towards the end of the two-year training period. The three worst scoring items seem to be related to when the trainees are on call.

Conclusion Perceptions of role autonomy and of social support are areas where most work is needed. Teaching seems to be moving in the right direction but there is always room for improvement.

Educational Philosophy and Theory

Educational environment

Clinical

Postgraduate

Malta

Foundation Programme

For healthcare professionals, there is no substitute to learning in the clinical environment (Nordquist et al.,2019). Learning from managing patients in a real-world context is by far superior to simulation learning. Over the past three decades, the subject of the educational environment, both at undergraduate and at postgraduate level, has been the focus of much research and discussion among all stakeholders in medical education. Both the GMC (2016) and Kilty et al. (2017) have underlined that a substandard educational environment is associated with poor patient care and suboptimal learning outcomes. Not only do young trainees learn from their work with patients, but patient care would suffer were these trainees to be removed from teaching organisations as their work is essential for any healthcare organization. This is further confirmed by the GMC (2016) when it states: “patient safety is inseparable from a good learning environment and culture that values and supports learners and educators”. The educational environment is, therefore, considered an important measure in both undergraduate and postgraduate medical training.

Postgraduate medical trainees have a dual contrasting role. On the one hand they are trainees, transitioning to hospital life, still in need of support and still adapting to their new responsibilities. On the other hand, as practicing doctors they need to provide answers to patients’ questions, work long hours, be accountable for their actions and may find inadequate support from their more senior colleagues. Trainees may feel under constant evaluation by their patients, colleagues and senior grades. This dual role is known to increase the risk of stress, anxiety, depression and burnout (Papaefstathioiu et al., 2019). Medical trainees are known to be one of the most vulnerable categories of employee to occupational stress (Antoniou, Davidson and Cooper, 2003)

The MACY Foundation (2018) sees the educational environment as:

“the social interactions, organizational cultures and structures, and physical and virtual spaces that surround and shape participants’ experiences, perceptions, and learning.” (Irby, 2018)

The American Medical Association defines educational environment as:

“a social system that includes the learner, the individuals with whom the learner interacts, the setting(s) and purpose(s) of the interaction, and the formal and informal rules/policies/norms governing the interaction” (Delva et al., 2004)

These definitions, among others, identify the complexity of the educational environment when compared to education in a class room.

The measurement of the educational environment provides an insight on what is needed to improve the level of training. This is done by identifying the weaknesses and strengths of a training programme and which areas should be prioritized in any improvement that is planned.

For many years, the educational environment was ignored, possibly because of the lack of suitable and validated instruments that could be used to assess it. This has now changed and a number of validated instruments to assess the different aspects or domains of the educational environment. One of the first to be developed was the Dundee Ready Education Environment Measure (DREEM) (Roff et al., 1997). DREEM uses five subscales in its evaluation of the education environment:

Students’ perception of learning
Students’ perception of teachers
Students’ academic self-perceptions
Students’ perceptions of atmosphere
Students’ social self-perceptions

Following DREEM a number of other instruments aimed at assessing the education environment in different settings were developed and validated. These include PHEEM (Postgraduate Hospital Education Environment Measure) (Roff, McAleer and Skinner, 2005), ATEEM (Anaesthetic Theatre Education Environment Measure) (Holt and Roff, 2004) and STEEM (Surgical Operating Theatre Education Environment) (Cassar, 2004). The PHEEM will be discussed in more detail at a later stage.

With the use of different measures of the education environment now widespread in the literature, such instruments can be used to gain holistic views of the curriculum, understand the students’ perceptions of learning, teaching and the atmosphere, compare the different perceptions of the various stakeholders, compare environments between schools or departments, provide organisations with indications of what needs to be changed or improved and to evaluate the results of any changes made on the education environment (Harden and Laidlaw, 2020).

The Malta Foundation Programme was founded in 2009. As the Malta Foundation Programme (MFP) bases its operations on the same Reference Guide, while offering the same Curriculum and training opportunities as the UK Foundation Programme (UKFPO), the MFP was awarded the status of Affiliate Programme by the UK Foundation Programme. This status has ensured that trainees of the MFP, upon completion of their programme, can compete on the same level as those completing the UK Foundation Programme for training posts in specialities in Malta, the UK or elsewhere. This affiliation has since been renewed at regular intervals after the MFP repeatedly fulfilled the Quality Standards of the Malta Medical Council and the UKFPO. (MFP, 2020).

A cross-sectional observational method was chosen for this study of the educational environment and burnout among Foundation Doctors in Malta.

The instrument chosen to assess the educational environment is the Postgraduate Hospital Education Environment Measure (PHEEM) questionnaire administered online through Google Forms to all doctors within the Malta Foundation Programme. The PHEEM questionnaire has been validated in various settings and in different countries. Minor changes were made to the wording of the questionnaire to ensure that each question is relevant to the Maltese setting. Direct correspondence with the original author of the PHEEM questionnaire ensured permission to use and validity of the minor changes to the wording.

PHEEM was administered in English as all medical tuition in Malta is carried out in English.The questionnaires were distributed to all Foundation Programme doctors via their year representatives in the form of a Google Form online questionnaire. As the Foundation Programme does not offer the service of forwarding emails directly, the questionnaire was initially be sent to the Foundation School Secretary who then passed it on to the foundation doctors’ representatives. A reminder was sent after seven days aiming at increasing the response rate. All respondents were requested to submit solely a single reply especially as this was an anonymous questionnaire. The period of data collection coincided in a period when three cohorts of Foundation Doctors could be sampled. The first years were sampled at the end of their first rotation, three months into practising. The second years were sampled between their first and second years, a year into practising. A third category, though technically not under the responsibility of the Foundation Programme, were the extended Foundation doctors. These were doctors who had successfully finished their Foundation training and were waiting for their BST posts to be decided. These trainees were sampled at the end of their two-year Foundation training. The sampling period ran between July and August 2020 for FY2s and extended FYs, and in October 2020 for FY1s.

A covering letter and a participant information sheet accompanied the questionnaire. Informed consent was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations. The deadline for the collection of data was two weeks after the reminder was sent.

Ethical approval was obtained from the University of Malta Faculty Research Ethics Committee and approval to disseminate the questionnaire was obtained from the Malta Foundation Programme.

The responses were analysed using SPSS 25.0. Questions 7,8,11 and 13 are negatively worded statements and needed to be reversed for scoring. Reliability tests of the whole instruments and the three factors was performed using Cronbach’s alpha. Descriptive statistics were used to describe the demographic features of the respondents. Tests for normality (Komogorov-Smirnov and Shapiro-Wilk) for all factors revealed that no question was normally distributed. Therefore, all comparative statistics were of the non-parametric type. The Mann-Whitney U test was used to analyse differences between genders. The Kruskall-Wallis H test was used to test for differences between Foundation years. The threshold for statistical significance was a p < 0.05 and 95% confidence interval. Factor analysis of all 40 items was also performed using both the scee plot and a criterion of an eigenvalue >1.

Demographics

98 trainees out of 370 (26.5%) completed the online questionnaire. These consisted of 39 FY1s (31.5% of 124), 33 FY2s (24.8% of 133) and 26 Extended FYs (23.0% of 113). 71.4% were aged between 23 and 25 years. 60.2% were female and 94.9% were single. 87.8% were Maltese. 86.7% worked in excess of the 48-hour week stipulated in the European Working Time Directive.

Internal Consistency

The 40-item PHEEM showed good reliability with a Cronbach’s α value of 0.912. Cronbach’s α for each of the three subscales of the PHEEM were as follows:

Autonomy – 0.790

Teaching – 0.885

Social support – 0.683

Item analysis

Table 1 summarizes the responses to each of the 40 questions according to year of training.

Table 1 summarizes the responses to each of the 40 questions according to year

		FY1s		FY2s		Extended FYs		Total
No.	Question	Mean	SD	Mean	SD	Mean	SD	Mean	SD
1	I have a contract of employment that provides information about hours of work	2.36	0.932	1.61	1.223	1.62	1.061	1.91	1.122
2	My clinical teachers set clear expectations	2.59	0.938	2.48	0.870	2.12	1.071	2.43	0.963
3	I have protected educational time in this post	1.82	1.189	1.67	1.267	1.92	1.383	1.80	1.260
4	I have an informative induction programme	2.36	1.088	1.82	1.044	2.12	1.033	2.11	1.073
5	I have the appropriate level of responsibility in this post	2.49	0.914	2.06	1.116	2.42	1.027	2.33	1.023
6	I have good clinical supervision at all times	2.87	0.978	2.39	1.171	2.69	1.158	2.66	1.102
7	There is racism in this post	2.44	1.188	2.48	1.093	2.62	1.359	2.50	1.195
8	I have to perform inappropriate tasks	2.00	1.051	1.52	1.093	1.69	1.289	1.76	1.140
9	There is an informative Junior Doctors handbook	1.82	1.023	2.30	1.132	2.27	1.002	2.10	1.070
10	My clinical teachers have good communication skills	2.85	0.875	2.79	0.820	2.65	1.056	2.78	0.903
11	I am bleeped inappropriately	1.13	1.005	0.58	0.902	0.96	1.399	0.90	1.108
12	I am able to participate actively in educational events	2.36	0.778	2.06	0.864	1.96	0.958	2.15	0.866
13	There is sex discrimination in this post	2.56	1.142	2.61	1.197	2.77	1.243	2.63	1.179
14	There are clear clinical protocols in this post	2.85	0.432	2.58	0.969	2.69	0.838	2.71	0.760
15	My clinical teachers are enthusiastic	2.54	0.884	2.30	1.015	2.38	0.983	2.42	0.852
16	I have good collaboration with other doctors in my grade	3.21	0.695	3.42	0.561	3.35	0.562	3.32	0.619
17	My hours conform to the European Working Time Directive	1.03	1.013	0.64	1.025	0.62	0.983	0.79	1.018
18	I have the opportunity to provide continuity of care	2.33	0.898	1.94	1.197	2.58	0.945	2.27	1.041
19	I have suitable access to careers advice	1.85	1.040	1.67	1.137	1.64	0.810	1.73	1.016
20	This hospital has good quality accommodation for junior doctors, especially when on call	2.08	1.178	1.45	1.325	1.73	1.218	1.78	1.256
21	There is access to an educational programme relevant to my needs	2.31	0.766	1.94	1.116	1.92	1.038	2.08	0.975
22	I get regular feedback from seniors	2.28	1.123	2.30	0.984	2.31	1.011	2.30	1.038
23	My clinical teachers are well organised	2.61	0.823	2.30	1.075	2.27	0.962	2.41	0.955
24	I feel physically safe within the hospital environment	2.62	0.963	2.45	1.003	2.38	0.983	2.50	0.977
25	There is a no-blame culture in this post	1.62	1.161	1.33	1.242	1.19	1.234	1.41	1.209
26	There are adequate catering facilities when I am on call	1.15	1.014	0.70	0.951	0.62	0.898	0.86	0.984
27	I have enough clinical learning opportunities for my needs	2.05	1.025	1.91	1.146	2.00	1.080	1.99	1.071
28	My clinical teachers have good teaching skills	2.74	0.751	2.61	0.899	2.58	0.902	2.65	0.839
29	I feel part of a team working here	2.92	0.870	2.75	0.718	2.77	0.992	2.82	0.854
30	I have opportunities to acquire the appropriate practical procedures for my grade	2.41	0.850	2.03	1.132	2.19	1.021	2.22	1.000
31	My clinical teachers are accessible	2.82	0.970	2.64	0.994	2.58	0.703	2.69	0.913
32	My workload in this job is fine	2.08	1.085	1.48	1.176	2.15	1.190	1.90	1.171
33	Senior staff utilise learning opportunities effectively	2.49	0.885	2.21	0.857	2.23	0.951	2.33	0.894
34	The training in this post makes me feel ready to be a BST	1.67	0.737	1.58	1.062	1.96	1.113	1.71	0.963
35	My clinical teachers have good mentoring skills	2.64	0.932	2.67	0.736	2.38	0.804	2.58	0.836
36	I get a lot of enjoyment out of my present job	2.38	0.935	2.06	1.116	2.12	1.071	2.20	1.035
37	My clinical teachers encourage me to be an independent learner	2.79	0.801	2.76	0.902	2.73	0.724	2.77	0.81
38	There are good counselling opportunities for junior doctors who fail to complete their training satisfactorily	1.87	0.656	1.30	0.883	1.58	0.987	1.60	0.858
39	The clinical teachers provide me with good feedback on my strengths and weaknesses	2.26	1.093	2.09	1.208	2.46	1.174	2.26	1.152
40	My clinical teachers promote an atmosphere of mutual respect	3.00	0.946	2.64	0.962	2.46	1.067	2.73	1.001

Table 2 illustrates the cumulative scores for the three themes and for the total PHEEM score for each of the three cohorts assessed in this study.

Table 2 Scores for the three PHEEM themes and total score

		FY1	FY2	Ext. FY	Total
Perceptions of Role Autonomy		30.44	25.42	28.50	28.23
0-14	Very poor
15-28	A negative view of one's role
29-42	A more positive perception of one's role
43-56	Excellent perception of one's job

Perceptions of Teaching		34.46	31.61	32.00	32.85
0-15	Very poor quality
16-30	In need of some retraining
31-45	Moving in the right direction
46-60	Model teachers

Perception of Social Support		26.26	23.82	23.88	24.81
0-11	Non-existent
11-22	Not a pleasant place
23-33	More pros than cons
34-44	A good supportive environment

Overall Score		92.15	81.97	85.46	86.95
0-40	Very poor
41-80	Plenty of problems
81-120	More positive than negative, but room for improvement
121-160	Excellent

The authors of PHEEM (Roff et al., 2005) recommend that any item with a mean of 2 or less should be examined in detail as it may indicate a problem area. Table 3 provides a summary of the items with a mean total score below 2 for the three cohorts in the study. The items have been arranged in ascending order.

Table 3 – Summary of the items with a mean total score below 2 for the three cohorts in the study. The items have been arranged in ascending order.

		Total
No.	Question	Mean	SD
17	My hours conform to the European Working Time Directive	0.79	1.018
26	There are adequate catering facilities when I am on call	0.86	0.984
11	I am bleeped inappropriately	0.90	1.108
25	There is a no-blame culture in this post	1.41	1.209
38	There are good counselling opportunities for junior doctors who fail to complete their training satisfactorily	1.60	0.858
34	The training in this post makes me feel ready to be a BST	1.71	0.963
19	I have suitable access to careers advice	1.73	1.016
8	I have to perform inappropriate tasks	1.76	1.140
20	This hospital has good quality accomodation for junior doctors, especially when on call	1.78	1.256
3	I have protected educational time in this post	1.80	1.260
32	My workload in this job is fine	1.90	1.171
1	I have a contract of employment that provides information about hours of work	1.91	1.122
27	I have enough clinical learning opportunities for my needs	1.99	1.071

There was only one question that was rated >3 by the three cohorts “I have good collaboration with other doctors in my grade”. Another question, “My clinical teachers promote an atmosphere of mutual respect” was rated 3.00 by Foundation Year 1 respondents. The original authors of PHEEM have suggested that items with a mean score 3.5 or over are real positive points. None were identified in this study.

Statistically significant differences between genders were identified on seven items as listed in Table 4. In general, females seemed to give higher rankings in almost all of the seven items. The only exception is the question regarding sex discrimination at the workplace.

Table 4 – items with statistical significance between genders.

Statistically significant differences between Foundation-year cohorts were identified in five items using the Kruskall-Wallis H test. These results are illustrated in Table 5.

Table 5 – items with statistical significance between years of training.

Generally speaking, mean scores seem to dip midway through the two-year training period, only to pick up again at the end of training, but never reaching the same levels as at the early stages of training.

Table 6- Factor analysis at Eigenvalue >1

Total Variance Explained
Component	Initial Eigenvalues			Extraction Sums of Squared Loadings
Component	Total	% of Variance	Cumulative %	Total	% of Variance	Cumulative %
1	10.367	25.917	25.917	10.367	25.917	25.917
2	3.258	8.146	34.063	3.258	8.146	34.063
3	2.049	5.123	39.186	2.049	5.123	39.186
4	2.016	5.039	44.225	2.016	5.039	44.225
5	1.743	4.357	48.583	1.743	4.357	48.583
6	1.625	4.063	52.646	1.625	4.063	52.646
7	1.521	3.803	56.449	1.521	3.803	56.449
8	1.302	3.255	59.704	1.302	3.255	59.704
9	1.211	3.028	62.732	1.211	3.028	62.732
10	1.151	2.877	65.609	1.151	2.877	65.609
11	1.077	2.691	68.300	1.077	2.691	68.300
12	.976	2.439	70.739
13	.938	2.345	73.085
14	.886	2.214	75.299
15	.850	2.126	77.425
16	.779	1.948	79.372
17	.737	1.843	81.216
18	.676	1.689	82.905
19	.626	1.565	84.469
20	.610	1.524	85.994
21	.537	1.342	87.335
22	.504	1.261	88.596
23	.476	1.190	89.787
24	.458	1.146	90.933
25	.415	1.038	91.971
26	.387	.967	92.938
27	.375	.937	93.874
28	.325	.812	94.686
29	.288	.721	95.406
30	.272	.681	96.087
31	.241	.601	96.688
32	.221	.554	97.242
33	.189	.472	97.714
34	.187	.468	98.182
35	.164	.410	98.592
36	.147	.368	98.960
37	.134	.336	99.296
38	.120	.300	99.596
39	.103	.257	99.853
40	.059	.147	100.000
Extraction Method: Principal Component Analysis.

Factor analysis

Principal component analysis of the 40 items making up the PHEEM questionnaire suggested the presence of 3 or 4 factors as identified by the inflexion of the points on the scree plot as seen in Figure 1.

Using a criterion of an eigenvalue > 1, 11 factors could be identified, accounting for 68.3% of the variance. The first factor had an eigenvalue of 10.367 accounting for 25.917% of the variance. The next ten factors had eigenvalues of >3.26, and explained 42.383% of the variance (see Table 6).

The current study evaluates the Foundation doctors’ perception of the educational environment at the Malta Foundation Programme. These doctors have perceived their educational environment as more positive than negative. There seems to be a dip midway through training. However, rankings improve towards the end of the two-year training period albeit never reaching the rankings at the start of training. Perceptions of teaching and of social support ranked higher than perceptions of role autonomy. Trainees have demonstrated particularly low rankings in perceptions of role autonomy midway and at the end of training.

Interestingly, out of the 11 items with a mean score less than 2, six form part of the autonomy sub-scale, five form part of the social support subscale and only two were part of the teaching sub-scale.

The three worst scoring items seem to be related to when the trainees are on call. Malta persists with a system of on call duties that has been scrapped in many countries. Under the current conditions, Foundation doctors work for some 28 hours at a stretch. While adoption of the European Working Time Directive is part of Maltese law, Foundation doctors may feel that if they choose not to exceed 48 hours of work in a week, they may find themselves at a disadvantage when applying for training posts at a later stage in their career. On call duties are made worse by the lack of proper catering facilities on site and by an inordinate number of inappropriate pages.

Statistically significant differences between genders were identified on seven items as illustrated in Table 4. Five of these items form part of the perceptions of role autonomy sub-scale and two form part of the perceptions of social support sub-scale. Female trainees gave higher rankings in all seven items except in “There is sex discrimination in this post”. It is encouraging to note that female trainees do not perceive the educational environment at the Malta Foundation Programme to be sexually discriminatory.

Foundation Year 1 trainees scored significantly higher on five items as shown in table 5 (3 items in the autonomy subscale and 2 in the social support subscale). There seems to be a trend of deterioration in perceptions across all items and subscales as training reaches its midpoint. Perceptions then improve by the end of training but never reach the same levels of ranking achieved at the start of training. Whether this could be related to the development of burnout in trainees will be analysed in a further study.

In a similar local study, Farrugia Jones and Cacciotolo (2009) had assesses the postgraduate educational environment in the Department of Medicine, at Mater Dei Hospital, Malta. The response rate for house officers in this study was 10%. Problem areas identified by trainees in this study were: the absence of protected time, no access to an individual educational programme and working hours which do not conform with the European Working Time Directive. The same problems have, unfortunately, again been highlighted by this study. Poor catering facilities, poor access to career advice and counselling opportunities, a strong blame culture and an inappropriate workload were also replicated in the current study.

The benefits of a healthy educational environment are multiple. Studies have shown that the learning environment is associated with the quality of care provided (Tamblyn et al., 2005). The educational environment also influenced the prescribing habits of trainees (Cadieux et al., 2007) and the management and use of health care services and resources (Chen et al., 2014). In surgical training, higher rated surgical training programmes were associated with lower complication rates (Bansal et al., 2016)

The importance of having a high-quality clinical learning environment stems from the knowledge that a high-quality learning environment will have a direct impact on workplace learning and on the quality and safety of the clinical care received by patients. Ultimately a high-quality educational environment should translate into better patient outcomes. Trainees exposed to a high-quality clinical learning environment will have been exposed to participation in the clinical care of patients in a supervised manner. They will also be exposed to coaching, assessment and feedback, deliberate practice and peer collaboration (Kilty et al., 2017).

As noted earlier “patient safety is inseparable from a good learning environment and culture that values and supports learners and educators” (GMC,2016). One needs to see this in the light that many trainees are meant to learn and develop their clinical skills in understaffed, underfunded, uncontrolled and overcrowded clinical educational environments (Karanikolos et al., 2013; Di Somma et al., 2015). Exceeding a certain critical level of workload will result in a decline in trainee learning. Heavy workloads were found to be linked to a number of undesirable outcomes in trainees. These outcomes include increased likelihood of burnout and lower engagement, health and well-being (Visser et al., 2003; Jennings and Slavin, 2015). Lower levels of patient satisfaction, poor standards of care and a higher mortality were also associated with self-reported heavy workloads (Dixon-Woods et al., 2014; Reader and Gillespie, 2013).

This study has limitations. The response rate was relatively low despite a reminder being sent. The quantitative nature of the study precludes an in-depth exploration of the reasons why trainees have the expressed perceptions. A qualitative additional study is warranted. The study was also carried out in a single centre albeit this is the only one on the island. The study did not take into account the effect of a pandemic on the educational environment.

This study was aimed at evaluating the educational environment at the Malta Foundation Programme. The first two years of postgraduate medical education signify a transition that can be rough and demanding as trainees are suddenly burdened with professional responsibilities. It is a period where learning has not ended with the undergraduate years but is only beginning in the postgraduate years.

The current study has identified areas in the educational environment where improvement is needed. Perceptions of role autonomy and of social support are areas where most work is needed. Teaching seems to be moving in the right direction but there is always room for improvement. Comparison with another local study has identified similar problem areas.

The study was conducted at a time where the COVID-19 pandemic was having its toll on the healthcare systems across the world. It may also have had an impact on the results of this study.

Perceptions of the educational environment among trainees are at their lowest midway during the two-year duration of the Foundation Programme.
Doctors in Malta are still subjected to working long hours during the week and at a stretch. This seems to be having its toll on their perception of the educational environment.
Perceptions of teaching and of social support ranked higher than perceptions of role autonomy.
Female trainees do not perceive the educational environment at the Malta Foundation Programme to be sexually discriminatory.

Ethics approval and consent to participate

Ethics approval was obtained from the Faculty Research Ethics Committee at the University of Malta. Permission to conduct the study was also obtained from the Foundation Programme, Malta. Informed consent was obtained from all participants.

Consent for publication

I give my consent for the publication of the manuscript

Availability of data and materials

All data can be downloaded here:

https://doi.org/10.6084/m9.figshare.13215428.v1

Competing interests

No competing interests to report

Funding

The author has self-funded this study.

Authors' contributions

Marco Grech was the sole contributor to this manuscript

Acknowledgements

Professor Sally Davies for her valuable guidance, advice and encouragement.

Authors' information

Dr Marco Grech is a Senior General Practitioner. He has served as Assessment Lead, AKT Lead and Education Secretary for the Malta College of Family Doctors. He is a visiting senior lecturer within the Department of Family Medicine, Faculty of Medicine and Surgery, University of Malta.

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An analysis of the Educational Environment at the Malta Foundation Programme using the Postgraduate Hospital Educational Environment Measure (PHEEM).

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