The theme of challenges during the residency period comprised 11 main categories and 48 sub-categories, as shown in Table 1. Some interviewees expressed that residency is an educational period, while others viewed it as a job. For instance, (P4) stated, "In my opinion, residency is an educational period, not a job." Meanwhile, (P16) remarked, "Residency is a job. According to some of the interviewees, there is a discrepancy in how residency is perceived, with some viewing it as an educational period and others as a job. For instance, a hospital manager (P4) stated, "In my opinion, residency is an educational period; it cannot be considered as a job." On the contrary, according to one of the attendees (P16), "Residency is a job, and a resident has certain responsibilities and tasks, along with some training; it is essentially a job that involves receiving specific training." Additionally, one of the healthcare financing specialists (P2) expressed that "residency adds value... residents work from morning till night, treating patients. Residency is a job."
Table 1
Medical Residency Challenges
Theme | Subtheme | Items |
Context Challenges | The Economic and Social Situation of the Country | Inflation and High Prices, Political Issues and Sanctions, Apathy and Discontent in Society |
Cultural Factors (Individual and Societal Expectations) | High Societal Expectations, Differences in Individuals' Expectations from the System, and Comparisons with Other Countries |
Challenges in the Education System | Planning Challenges | Lack of a comprehensive, residency program, Mismatch between society's needs and education Inadequate number of students relative to the workload in certain fields or regions, Insufficient educational infrastructure, including beds and faculty, in proportion to the number of students, Limited patient diversity due to a high number of students, Unclear job status for individuals before the start of their education, The need for a reassessment of the duration of residency programs in some fields, Excessive reliance on diagnostic technologies |
Inappropriate Resident Recruitment Methods | Selection of unmotivated and uninterested individuals, low skill levels and abilities of some residents, admission of incompetent individuals to the program, entry into fields without proper knowledge |
Challenges in Residency Training | Faculty members' lack of familiarity with modern teaching methods, Inappropriate selection of faculty members, Inconvenient teaching hours, Inadequate or inappropriate educational curricula ,Self-completion of theses by residents, Unclear job descriptions for residents in different years of the program, Thesis requirement as a graduation condition, Inadequate supervision of attending physicians over residents, Professors using their discretion to assign punishments to residents as a disciplinary tool |
Weak Existing Laws and Guidelines | Failure to Implement Existing Guidelines, Lack of Setting Shift Limits |
Main Job-Related Challenges | Shortage of Welfare Facilities | Lack of Insurance, Absence of Resident Accommodations, Lack of Liability Insurance |
High Workload | Heavy Patient Loads, Excessive Work, High Patient Volume, Residents Handling a High Volume of Service Delivery |
Income Challenges | Inadequate Income Relative to Workload, Working in Private Hospitals, Rising Cost of Living, Livelihood Challenges |
Communication Challenges | Lack of appropriate communication between attendings and residents, Inappropriate confrontations, Military-like confrontations, Development of unhealthy behavior, Absence of attendings, Hierarchical abuse by lower-year medical students, Pressure on residents due to attendings' dissatisfaction with government sector income |
Identity and Role Characteristics | Predominance of Therapeutic Role, Lack of Share in Hospital Income, Limited Decision-Making Power of Residents |
Future Career Challenges | Low Income during Training Program, Uncertainty about Future Job Prospects, Progressive Taxation Scheme, Low Income during Training, Limited Job Market |
Low Tariffs and Payment Delays | Low Tariffs, Payment Delays, Lack of Tariff Growth, Inadequate Attendings' Income |
Consequential Challenges | | Presence of unmotivated and disinterested individuals, Resignations, Suicides, Physical and mental exhaustion of current assistants, Development of unhealthy behavior, especially after completing residency, Mistreatment of residents, Underground economy, Migration, Production of doctors for other countries, Lack of interest in residency programs by, doctors and a continuous decrease in residency applicants, Underutilized capacity, Increase in medical errors, Reduction in the quantity and quality of services provided |
The first subtheme, "Context Factors (Socioeconomic Conditions, Individual and Societal Expectations)," emerged as one of the factors contributing to the challenges of residency.
Some interviewees pointed to economic issues and inflation as significant challenges. (P1) stated, "Since 2014, when the electricity tariff lagged behind, it hasn't improved much. Every year it's around 10 to 15 percent, while inflation is between thirty to forty percent. So, we're facing a severe regression." (P12) also highlighted the financial challenges, saying, "In 2017, surgery used to cost 9,000 tomans, but after 5 years, when I left that system, it had risen to 13,000 and something. Compare its growth to the country's inflation rate. This, along with insurance companies' delays in payments, is demotivating for all residents. With the delay they impose, given the inflation rate, it practically means 10 to 20 percent less for you. Just calculate in a country with an 8-month delay. How much was the price of a car 8 months ago, and what is it now? The value of money keeps decreasing. There's also a hidden tax here."
Another internal factor discussed as a challenge in the context of resident expectations is the psychological pressure it puts on residents. One of the participants (P6) mentioned, "You are a resident, you are a physician; everyone sees you as a specialist doctor, but you can't even afford to pay for your child's education, not even in a public exemplary school, let alone a private one. It's natural that a person gets frustrated." In line with this, another interviewee (P4) emphasized the importance of income, stating, "Income is essential, and I really emphasize it. If I don't have an income, even though I'm not young anymore, I was a general physician, then a specialist assistant, the family pressures me to get married. Now that I'm married, where should I get the resources to provide for my life?"
In the second thematic category: Challenges in the Education System (Challenges in Residency Program Planning, Inappropriate Resident Recruitment Methods, Challenges in Residency Training Implementation, Existing Laws and Guidelines), several topics were discussed by the participants:
One of the issues raised by participants was the lack of comprehensive planning for the residency program. For example, participant (P9) stated, "In the past, when society needed doctors, the average university admission rate was suitable for these individuals. Currently, the demand for doctors has decreased, but we are still admitting medical students, and the future prospects are uncertain." A hospital resident (P10) expressed, "They lack motivation. It's disheartening when a graduate says they don't know what to do." In this regard, another participant (P8) mentioned, "We don't have any well-defined and comprehensive program at the macro level for the residency program."
Another topic discussed was the educational challenges, where participants noted that education has become secondary, and the focus has shifted more towards patient care in residency programs. An emergency medicine specialist (P3) believed, "In these demanding shifts, patient care takes precedence, and education is sacrificed. This leads to a lack of interest among students in various medical fields, resulting in a shortage of competent residents." (P4) "The residency program is tough, and some teaching hospitals treat residents as mere workers, justifying their hardships."
Some participants also identified challenges related to the increasing number of medical students. One participant (P11) pointed out the capacity issue, saying, "The discussion of increasing capacity is crucial. In the past, we used to admit only a few residents, but now we admit many, resulting in insufficient resources and time for proper training."
Participants discussed challenges in the teaching methods. According to one participant (P4), "There has been a heavy reliance on technology in education. Previously, senior professors used to conduct thorough patient examinations, but now they delegate basic tasks to assistants." In this context, another participant (P12) expressed, "In my opinion, the current educational program provided by the faculty is limited to morning reports that are held for half an hour or 45 minutes in the morning. These morning reports often lack a substantial educational aspect." One of the stakeholders (P16) emphasized the importance of well-trained educators who understand the residents' expectations and adhere to teaching principles, including their behavior, speech, and interactions.
In the third thematic category: Work-Related Challenges (Welfare Concerns, High Workload, Low Income, Communication Factors, Role and Identity, Future Career Challenges, Low Tariffs Rates)
One of the topics that participants raised as a challenge in residency was welfare concerns. One of the outspoken individuals (P6) stated, "We neither provide them with sufficient salaries nor offer minimum welfare facilities. We cannot even provide married housing facilities, and in these initial matters, we have not provided the necessary support, and we cannot do it." In the same vein, another participant (P3) believed, "On the one hand, they don't have sufficient salaries, and on the other hand, they receive some educational assistance, but they don't have proper insurance." A hospital manager (P4) also mentioned in this regard, "These residents neither have insurance nor do we account for their seniority, and this is a problem." One of the contributors (P18) expressed, "Residents should not have financial concerns. We had residents, and I called their attention to it; their salaries had increased significantly. I checked, and they hadn't gone home for 26 nights. I asked, 'So, when are you studying? From morning till night, you're on duty.' And they replied, 'Who is going to provide a home for me?'"
Another challenge of residency is the high workload. Participants believed that residents bear the responsibility of patient care and service delivery in teaching hospitals, leading to a high workload and resulting pressure on residents. One of the participants (P1) stated, "Residents play a significant role in managing government hospitals. In other words, government hospitals are primarily managed by residents." In this regard, another participant (P6) expressed, "Unfortunately, the treatment load in teaching hospitals is placed on the shoulders of residents entirely. All the treatment load, while there is a need for a ceiling in education, not only is ineffective in education but also can be destructive." (P4) "Long shifts are really one of the problems they have always had. 36-hour, 48-hour, and even 72-hour shifts. After all, we are all human beings, and we can make mistakes and errors can certainly happen."
One of the primary concerns that interviewees consider as one of the most critical challenges of the residency period is the income challenge. One of the participants (P6) stated, "On the one hand, residents' livelihoods are under pressure. At the global level, when someone becomes a resident, they have a minimum income, not to say that it is sufficient, but they have a minimum income that can sustain their student life, and the livelihood concern should be minimized." A hospital director (P12) mentioned, "...from a certain point, especially since 2017, especially the little bird's tax scheme they implemented in 2016, and as a result of that, the economic conditions of the country changed in a way that the real and monetary value emerged, and alongside that, medical tariffs did not increase at all. In 2017, surgery was 9 thousand Tomans, and after about 5 years when I came out of that structure, it had become 13 thousand and a little, compare its growth rate with the inflation rate of this country. This is an issue, the insurance companies' failure to pay, horrible delays of 7 or 8 months for specialists, these have taken away the motivation from all residents." One of the university vice-deans (P14) stated, "The most important problem in residency is this, of course, everywhere we have become accustomed to cheap labor without preserving respect."
One of the concerns raised by the interviewees as challenges during the residency period is the communication and behavioral challenge with residents during their training. In this regard, one of the participants (P6) stated, "There are some psychological pressures in the departments, unfortunately, the educational atmosphere, they call it militarism, but it's not like that in practice, the insults that are directed at junior assistants are a bit unjust in this space, not a beautifying environment for education." An attendee (P8) mentioned, "I was an intern at a hospital; a first-year resident had no right to sleep, and there were three beds in that room with three interns and one resident, who took two beds and no intern could sleep there." A specialist (P10) expressed, "Unfortunately, some have personality issues. Some do not talk properly with residents and insult or make nasty remarks everywhere."
Another topic predominantly discussed by attendees was the identity and role characteristics of residents. In this regard, one of the attendees (P3) stated, "The motivation of students has decreased significantly, and there is no more motivation to just get through the period, and they are looking to emigrate, and the others are looking for more attractive fields." One of the interviewees (P4) remarked, "In general, I can say that there has been a wave of disillusionment among resident kids and young people today, which has affected this profession more."
One of the main internal factors affecting both career prospects and hospital payment capabilities is the service tariffs. In this regard, one of the participants (P1) stated, "See, three or four events have happened simultaneously or better say four events. First, the tariffs did not grow in line with inflation after 2014, ... Second, the delayed payments of insurance companies, which are a year behind. Third, the gradual increase in the insurance premium, which, as it approaches 60 million Tomans, decreases the amount between, it was supposed to reach 60 million, but now we did something that starts from 10 or 20 million to reduce, and this is very bad, and fourth, the additional graduated tax." According to one of the participants (P18), "See, the tariffs are not good, for example, for a Cesarean section with an anesthetist, they deduct costs, which can be as low as 100,000 Tomans, meaning what? Calculate the cost of surgery. Putting a digit for appendectomy that the Council of Ministers approved this year is 58,000 Tomans, how much does a surgeon get? For an appendectomy operation, it's less than 300,000 Tomans. You can get less for tube opening.
The fourth category of challenges in the residency period is the consequential challenges, which are the result of dissatisfaction or the impact of other challenges.
Participants identified these as one of the problems during their residency. One of the hospital directors (P12) stated, "In my third year of residency, I experienced severe depression with all the price increases, and I felt like I had taken a step back in the four years of studying and entering residency, and I made a mistake." Another resident (P15) expressed, "The level of education in hospitals needs to be improved; it's a flawed cycle where they don't pay the professor, or they force him to teach, and he has no motivation for teaching. The professor doesn't motivate the resident, and the resident transfers this lack of motivation to the intern; it's a flawed cycle, and all the problems are financial." (P3) mentioned, "The motivation of students has decreased significantly, and there is no more motivation to just get through the period, and they are looking to emigrate, and the others are looking for more attractive fields."
The interviewees presented 8 main themes with 52 interventions as solutions to improve the residency period. After two Delphi rounds involving 17 of the participants, these interventions were reduced to 45, with the most important interventions presented in Figure 1