What Works in Appraisal Meetings for Newly Graduated Doctors? – and What doesn't ?

doi:10.21203/rs.3.rs-518444/v1

PDF

Research Article

What Works in Appraisal Meetings for Newly Graduated Doctors? – and What doesn't ?

https://doi.org/10.21203/rs.3.rs-518444/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 22 Apr, 2022

Read the published version in BMC Medical Education →

You are reading this latest preprint version

Background: In Denmark, an educational advisor is assigned to all doctors in each clinical rotation of postgraduate medical education. The advisor conducts at least three appraisal meetings with the trainee to guide and oversee his/her work and learning progress.

This study explores why trainees evaluated the advisory program as either beneficial (successes) or not beneficial (non-successes).

Methods: Inspired by the Success Case Method, a survey was conducted among all 129 doctors employed in their first six-month clinical rotation of postgraduate medical education in the Central Denmark Region. A cluster analysis resulted in groups with eight successes and seven non-successes. Semi-structured interviews were conducted with six successes and five non-successes.

Results: In contrast to non-successes, the successes had longer appraisal meetings and their advisor introduced them to purpose and process of meetings including use of the personal learning plan. Successes received feedback on clinical skills, overall global performance and career plans. The successes perceived their advisors as prepared, skilled and motivated and the advisor acted as a contact person.

To the successes, the appraisal meetings fostered clarification of and reflections on educational goals, progress and career as well as self-confidence and a sense of security.

Conclusion: Success with appraisal meetings seemed to depend on advisor’s skills and motivation including willingness to prioritize time for this task.

The results from this study indicate the importance of faculty development. It also raises the question if all doctors should serve as advisors or if this task should be assigned to the most motivated candidates.

Educational Philosophy and Theory

Educational Psychology

Special Education

Appraisal meetings

Learning plans

Educational advisor

Faculty Development

Postgraduate Medical education

Ensuring the appropriate knowledge, skills and behavior of doctors in clinical training (trainees) is one of the keys to provide excellent care and ensure patient safety. Medical educators thus increasingly aim to provide standards for general and individual training. To ensure that these standards are met, an experienced doctor must guide and supervise the work and progress of each trainee in accordance with the specific learning objectives and milestones for each clinical rotation period as well as the entire specialist training program (postgraduate medical education).

The organization of trainee supervision in postgraduate medical education varies between countries ranging from voluntary mentor-mentee relations to structured mandatory programs with appointed educational advisors. Previous qualitative studies have described that successful mentor-mentee relations in academic medicine are characterized by reciprocity, mutual respect, clear expectations and personal relations (1). A literature review focusing on mentoring in emergency medicine recommended clarification of expectations of both mentor and mentee, structure with regular meetings and identification of the mentee's short and long-term goals (2). The mentor’s ability to act as an active listener, identify potential strengths in the mentee and assist the mentee in defining and reaching goals facilitates good mentoring relationships (3). Among residents, attention to personal development and mentors reporting on mentee progress was associated with an overall satisfaction with the mentorship (4). A more recent thematic review found that postgraduate mentees request their mentors to have professional experience and network connections and also be able to provide research-related, professional and emotional support (5).

This study took place in Denmark where a national formal advisor program (NFAP) is a mandatory part of postgraduate medical education (6). The purpose of the NFAP is to ensure professional development in accordance with learning objectives in the curriculum. In this program, a designated educational advisor (EA) is appointed to every trainee in each clinical rotation period. The definition and the tasks of the EA are listed in Fact box 1.

Fact box 1: The definition and the tasks of the educational advisor (EA)

In 2018, we published the results from a questionnaire study on implementation of the NFAP among trainees employed in their first six-month clinical rotation of the postgraduate medical education (PGY1 doctors) in Central Denmark Region. We found that overall appraisal meetings and learning plans were well implemented and supported the development of clinical competences, although learning plans were developed with delay, lacked plans for assessment and were not regularly adjusted (7). The questionnaire study thus documented implementation or lack of implementation of meetings and plans but did not reveal which elements in the NFAP contributed to a perceived success for the PGY1 doctors.

The aim of the current study was to explore PGY-1 doctors’ perception of a structured advisory program to identify differences between the PGY1 doctors who evaluated the NFAP most (success) and least (non-success) beneficial using the Success Case Method.

In this study the Success Case Method (SCM), a research-based mixed methods approach to explore the effect of an organizational initiative was used (8). The SCM analyses and compares participants with most success with those with least success. In this way our study differs from most studies on mentoring and advisory programs using questionnaires or interviews of a total population or a random sample of participants to find mean results.

The SCM consists of two steps: A survey identifying the most likely successes and non-successes followed by individual interviews with about a handful of representatives from the potential successes and non-successes to uncover major differences between success and non-success with a specific initiative (8).

Step 1: Survey

A survey was conducted among all 129 PGY-1 doctors in their first clinical rotation in Central Denmark Region.

The questionnaire was developed by the researchers and constructed to match the rules and recommendations by the Danish Ministry of Health regarding NFAP (9). The development of the questionnaire and main findings from the survey have been described previously (7).

Of 115 actively employed doctors, 67% (77/115) completed more than half the questions and were included in the cluster analysis to identify a small number of successes and non-successes, respectively.

Step 2: Interviews

Semi-structured interviews were conducted with six potential successes and five potential non-successes.

The experienced interviewer as well as the participating PGY1 doctors were blinded to the category of the success or non-success prior to the interviews to reduce the risk of bias and ensure an explorative approach.

In accordance with the SCM, the interview guide included questions addressing what was used from the appraisal meetings and the personal learning plan, results and value as well as (possible) facilitators and barriers (8).

Two interviews were carried out face-to-face after the interviewer had observed an appraisal meeting; the rest of the interviews were conducted by telephone. The interviews lasted between 25 and 35 minutes and were audio-recorded and transcribed verbatim.

Transcriptions were read through several times and subsequently analyzed following the qualitative content analysis approach (10) by the authors PA and AS. First, initial codes were generated, discussed and further explored in relation to the full data set. Secondly, memos were written and discussed among all four authors before agreeing on main themes. Finally, findings were categorized according to the SCM “buckets”: "What was used? (how, when and where)", "What results were achieved? (what was different)", "What good did it do? (value of result)", "What helped?" and "What were the barriers?" (8); six themes emerged.

The interviews revealed several major differences between the interviewed six PGY1 doctors with potential success and the five PGY1 doctors with potential non-success. The main results are described according to the SCM categories mentioned above. Subsequently, results are summarized and grouped in the six themes illustrated by quotations from the PGY1 doctors (Table 1).

What was used?

There were clear differences between the length of the appraisal meetings. We found that successes had appraisal meetings lasting approximately 60 minutes, whereas the non-successes described their meetings as short and rushed - sometimes as short as 10 minutes. The successes experienced a clear introduction to the purpose of the meetings. Also, successes were introduced to the learning plan template and expected to use it. Furthermore, the successes, in contrast to the non-successes, were offered career guidance and received feedback on overall global as well as clinical skills performance. Overall, the successes perceived their EA as a contact person.

What results were achieved?

The successes expressed the importance of having a personal relation to the EA and someone to address problems to. Introduction to the purpose and process of appraisal meetings facilitated structured conversations and matching of expectations. The PGY1 doctors in the success group stated that using the learning plan helped them and their EA to be prepared for the meetings and also contributed to clarification, follow up and adjustment of learning objectives. In this way, the learning plan became an effective tool for successes to take control of their education in a busy clinical setting. Compared to the non-successes, the successes experienced a more individualized conversation with their EA including ideas on what to do different in the daily work as well as discussions of background, strengths, challenges and interests.

What good did it do?

Overall, the six successes experienced the appraisal meetings as meaningful and helpful, and used them to gain overview of the purpose and goals of their current clinical rotation. Moreover, it helped them to keep track of both their progress, and areas where they needed to improve. In this sense, the meetings both helped them reach goals and set new milestones as well as reflect on their learning. The perception of a genuine interest from the EA in the PGY1-doctor as a person made the successes feel more welcome at the department. Feedback on clinical skills lead to increased professional confidence and discussions on background, interests etc. and lead to clarification of relevant career options. The non-successes received feedback on ongoing clinical problems but not on their general professional development.

What helped?

Knowledge, attitude and experience of the EA were themes for perceived success. Deep insight in the NFAP and the use of the personal learning plan as a tool to facilitate the professional development was experienced as very helpful for the successes. Frames for the appraisal meetings, a clear agenda and prioritization of time were important factors. The ability of the EA to show empathy, engagement and interest for the PGY1 doctor contributed to the perception of the EA being a contact person. The EAs of successes also included information from colleagues in their feedback to the trainee's overall global performance.

What were the barriers?

The EAs of the non-successes were perceived as indifferent to the PGY1 doctors and to the task of being an EA. There was a lack of knowledge of the purpose and process of the appraisal meetings and of how to use the personal learning plan. Clinical workload was perceived as a barrier and appraisal meetings were often cancelled with short notice. Another difference was the experience of non-successes of not getting any feedback on their overall clinical performance or only feedback on urgent or current situations. The non-successes did not receive any career guidance – some even experienced ignorance when trying to bring up a carrier issues.

The non-successes expressed that their EA regarded appraisal meetings and the personal learning plan as a bureaucratic formality without any value.

In this study, the SMC was used to distinguish participants who experienced the most and the least success of the appraisal meetings as a part of a mandatory NFAP. We found that the perception of success was associated with the duration of appraisal meetings, the relationship with the EA, introduction to the purpose, guidance in development and use of personal learning plans, feedback on performance as well as career guidance. Each theme is discussed below.

Longer appraisal meetings

Our study demonstrated that the duration of the meetings was longer for successes than non-successes. Both successes and non-successes described lack of time as a barrier to appraisal meetings. Successes perceived the advisors managed to allocate sufficient time and thereby demonstrating willingness to prioritize time for appraisal meetings.

There is no consensus on frequency or duration of meetings in mentoring relationships (1, 5), although lack of time is a well described barrier to effective mentoring (2, 11, 1, 12, 13, 14, 15). The latter corresponds with our result that too short and rushed meetings had a negative impact on trainees' perceived benefits of the NFAP. Several authors have suggested scheduled meetings, protected time or time allocated in the job plan (14, 13). However, this does not necessary circumvent the issues with lack of time, as even allocated time can be impinged by the clinical workload pressure (13).

Even though our results showed a positive relation between time used and satisfaction with appraisal meetings, it did not prove causality. However, meetings can probably be too short to make a positive difference for the guiding of trainees’ work and progress. This suggests enrolling only senior staff prepared to allocate time to manage the role of the EA (16).

A contact person – personal relations

The success PGY1 doctors in this study perceived their EA as approachable, dedicated and engaged. Previous studies of mentoring in medical education have found that mentors should ideally have seniority, be approachable and accessible, understanding, patient, dedicated, responsive as well as active listeners (17, 14, 11, 3, 2, 18). Effective mentors should proactively check in with mentees to see how they are doing (1). Some stressed the importance of selecting motivated and engaged mentors, ensuring that these have an interest in professional development in the workplace (19). Finally, perceived closeness to the mentor at work seems important to the mentee (17, 16).

The present study supports the importance of appointing only motivated doctors to the role as EAs.

An introduction to purpose and process

In the case of the successes, clarification of the purpose and process of the appraisal meetings lead to more structured conversations, leaving time and space for reflection. In contrast, the non-successes reported no introduction to the meetings. This might have had a negative impact on the perception of non-successes of the appraisal meetings, since clarifying mutual expectations at the beginning of a mentoring relationship are found critical to building effective mentoring relationships (2, 1, 16, 5). Furthermore, it points out the importance of faculty development to supply advisors with proper knowledge of the advisory system and skills on how to use learning plans and give feedback (11, 1, 20). In this way the organization demonstrates value of learning in the workplace (21) and recognizes the role that faculty development plays in curricular changes and development (22, 11, 19).

The present study supports the relevance of faculty development to achieve success in mentoring or advisory programs. It would be relevant to study if faculty development contributes to increase the motivation to act as mentors and EAs.

Help in using the learning plan

The successes were guided in the development and use of the learning plans, which worked as a tool to initiate reflections before appraisal meetings, and as a basis for the conversation with the advisor. To the successes, the learning plan became an effective tool to take control of their education in a busy clinical setting. However, if the learning plan was regarded a formality by the advisor and / or the trainee, or if neither of them understood or acknowledged its role as a tool, the learning plan became a demotivating factor as was the case for the non-successes.

Individualized learning plans are supposed to help improve development of self-directed, lifelong learning by actively engaging learners to take ownership of their own learning (23, 24, 25). Individual learning plans may serve as a checklist to frame the mentor's meetings with the mentee (1). However, trainees need help from seniors to develop and use their learning plans (23, 16, 26).

In order to be helpful, a learning plan must probably be revisited on a regular basis. This must be encouraged, since around half of the trainees did not remember to work on their learning goals on a regular basis according to a study by (24).

Thus, data from the present study support the relevance of a personal learning plan as a tool to support professional development, but also the importance of guidance and encouragement from the EA to use the plans.

Feedback on both clinical skills and overall global performance from the perspective of the PGY1 doctors was a valued part of the appraisal meetings for all participants in our study. However, feedback on clinical performance should take place in the daily clinical work (27). It has been suggested to make a clear distinction between educational and clinical supervision (16). Educational supervision involves support of the individual trainee with agenda-setting and planning in the context of a training program. Moreover, it should incorporate overview of the progress in the light of independent assessments of the trainee’s clinical performance, carried out by clinical supervisors (16). Clinical supervision, on the other hand, draws on the training agenda agreed upon with the educational supervisor to identify and support the training required.

This suggests that appraisal meetings should merely focus on global performance, passing millstones, as well as setting new goals for professional and personal development, which is actually the intension with the appraisal meetings (28) therefore, faculty should discuss the purpose of the meetings as well as the tasks of an EA to ensure the distinction between clinical and educational supervision. This might lead to a more fruitful feedback on overall performance in the appraisal meetings.

Career guidance

Career guidance is a mandatory part of appraisal meetings. To the successes, the inclusion of career guidance in the appraisal meetings contributed to reflections on relevant career choices on the background of discussions of e.g. strengths and interests. The non-successes reported receiving little or no career guidance.

Mentoring is important to career progression (29, 4), and it is relevant to combine advisors’ feedback on progression of clinical performance with career guidance, as trainees’ strengths and weaknesses should be essential to reflections on choice of career (1, 20).

Based on the results of the present study, career guidance should be carried out by the EA as he/she ideally has an overview of the competences of trainees and through the appraisal meetings the EA has the opportunity to discuss relevant career options on the background of the trainee's strengths and weaknesses. It is possible that PGY1 doctors with no or insufficient career guidance may experience problems in their career progress. However, further studies are needed to explore the influence of lack of career guidance on future career.

Limitations and generalizability

It was a limitation in our study that only the PGY1 doctors were interviewed. Thus, the results presented here represent only their perspective. As success in appraisal meetings presumably depends on both the EA and the trainee and the relation they are able to build, it would be interesting to explore the perspective of the EAs and to observe the interaction between advisors and trainees.

As we found no studies on organizational systems comparable with the NFAP, we have chosen to discuss the results from the present study with results from studies on factors important to success or failure of mentoring. In this light, our findings seem representative.

The majority of interviews were relatively short telephone interviews, and there was thus only limited time to build a relationship with the informants. Furthermore, the interviewer had limited familiarity with the NFAP at the beginning of the study. Thus, themes that emerged during the first interviews might have been more deeply explored. Continuing sampling until saturation of themes was not intended as the sample size was given by the cluster analysis in accordance with the SCM. However, we found a substantial agreement between the themes of importance to successes and non-successes, respectively. All authors participated in the data analysis, discussion of themes and sub-themes, thus increasing the dependability of the study.

To be successful, in the perspective of PGY1 doctors, appraisal meetings should be of appropriate length and the purpose and process of both the meetings and the personal learning plan should be introduced. The EA should function as a contact person and the meetings should include feedback on global performance, professional development and progress as well as career guidance.

Appraisal meetings can provide clarification of and reflections on educational goals, progress and career as well as self-confidence and a sense of security for trainees, but success depends on advisor’s skills, motivation and prioritization. This indicates the importance of faculty development to take on the role as educational advisor, but it also raises the question if all doctors should serve as advisors or if this role should be assigned to the most motivated candidates.

EA: A designated educational advisor

NFAP: A national formal advisor program

PGY1 doctors: First year of the postgraduate medical education

SCM: The Success Case Method

Ethics approval and consent to participate

The study followed the rules of the World Medical Association Declaration of Helsinki. Data were handled according to the rules by the Danish Data Protection Agency, who, according to Danish legal requirements approved the study (2012-58-006). The study was exempted from ethics approval according to the Act on Research Ethics Review of Health Research Projects. Act number 593 of July 2011, section 14 (30).

Before the interviews were carried out, information of the study was given to the participating PGY1 doctors by e-mail and verbally immediately before the interview. All participants were invited to speak freely and assured that all data would be anonymized, and any personal identifiable information would be left out. Written informed consent was obtained from all interviewed PGY1 doctors.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available due to the risk of compromising individual privacy, but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Dr. Sørensen was financially supported in part by a grant from Central Denmark Region.

Authors´contributions

The authors Marianne Kleis Møller (MKM), Pernille Andreassen (PA), Anita Sørensen (AS) og Bente Malling (BM) all made substantial contributions to conception and design of the study. PA performed the interviews. PA and AS carried out the first analysis. PA, AS, MKM and BM all contributed considerably to the following analysis and interpretation of data. PA, AS, MKM and BM all contributed to the drafting of the article and all read and approved the final manuscript.

Acknowledgements

We thank all the PGY1 doctors for participating in this study as well as the Secretariat of Postgraduate Medical Education, Northern Educational Region, Denmark and Human resource departments at hospitals in Central Denmark Region identifying doctors for inclusion. We thank, the library at Viborg Regional Hospital, Central Denmark Region for help in designing search strategies and our statistical advisor Max Schmelling, Innometric. Finally, we would like to acknowledge Marianne Godt Hansen for correcting the language and Pia Vestergaard Soelberg for layout of table.

Straus SE, Johnson MO, Marquez C, Feldman MD. Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers. Acad Med. 2013 Jan;88(1):82–9.
Yeung M¹, Nuth J, Stiell IG. Mentoring in emergency medicine: the art and the evidence. CJEM. 2010 Mar;12(2):143–9.
Williams LL et al: The Good-Enough Mentoring Relationship (Academic Psychiatry 2004; 28:111–115
Ramanan RA, Taylor WC, Davis RB, Phillips RS. Mentoring and Career Preparation in Internal Medicine Residency Training J GEN INTERN MED 2006; 21:340–345.
Sng JH, Pei Y, Toh YP, Peh TY, Neo SH, Krishna LKR. Mentoring relationships between senior physicians and junior doctors and/or medical students: A thematic review. Med Teach. 2017 Aug;39(8):866–875.
Danish Ministry of Health. Recommendations no 9586 af 14/07/2008: In Danish
Sørensen A, Møller MK, Andreassen P, Malling B. A SWOT analysis of how the youngest doctors perceive the formal Danish educational advisory program. Dan Med J. 2018 Sep;65(9).
Brinkerhoff RO. The Success case Method. Berrett-Koehler Publishers. San Francisco. 2003. ISBN 1-57675-185-6
Danish Ministry of Health. Executive order no 25/10/2007: Executive Order on the Training of Medical Specialists, 2007. In Danish
Emmerson RM, Fretz RI, Shaw LL: Writing Ethnographic Fieldnotes, 1995 University of Chicago Press
Straus SE¹, Chatur F, Taylor M. Issues in the mentor-mentee relationship in academic medicine: a qualitative study. Acad Med. 2009 Jan;84(1):135–9.
Kashiwagi DT, Varkey P, Cook DA. Mentoring programs for physicians in academic medicine: a systematic review. Acad Med. 2013 Jul;88(7):1029–37.
Webb J, Brightwell A, Sarkar P, Rabbie R, Chakravorty I. Peer mentoring for core medical trainees: uptake and impact.Postgrad Med J. 2015 Apr;91(1074):188–92.
Sambunjak D, Straus SE, Marusic A. A systematic review of qualitative research on the meaning and characteristics of mentoring in academic medicine. J Gen Intern Med 2009;25:72–8.
Ogdie A, Sparks JA, Angeles-Han ST, Bush K, Castelino FV, Golding A, Jiang Y, Kahlenberg JM, Kim AHJ, Lee YC, Machireddy K, Ombrello MJ, Shah AA, Wallace ZS, Nigrovic PA, Makris UE; Barriers and Facilitators of Mentoring for Trainees and Early Career Investigators in Rheumatology Research: Current State, Identification of Needs, and Road Map to an Inter-Institutional Adult Rheumatology Mentoring Program. Arthritis Care Res (Hoboken). 2018 Mar;70(3):445–453.
Mellon A, Murdoch-Eaton D. Supervisor or mentor: is there a difference? Implications for pediatric practice. Arch Dis Child. 2015 Sep;100(9):873–8.
Flint JH, Jahangir AA, Browner BD, Mehta S. The value of mentorship in orthopedic surgery resident education: the residents' perspective. J Bone Joint Surg Am. 2009 Apr;91(4):1017–22.
Woods SK, Burgess L, Kaminetzky C, McNeill D, Pinheiro S, Heflin MT. Defining the roles of advisors and mentors in postgraduate medical education: faculty perceptions, roles, responsibilities, and resource needs. J Grad Med Educ. 2010 Jun;2(2):195–200.
Billett S. Toward a workplace pedagogy: Guidance, participation and engagement. Adult Education Quarterly. 2002; 53: 27–43
Ssemata AS, Gladding S, John CC, Kiguli S. Developing mentorship in a resource-limited context: a qualitative research study of the experiences and perceptions of the Makerere university student and faculty mentorship programme. BMC Med Educ. 2017 Jul 14;17(1):123.
Steinert Y: Faculty development in the health professions. A focus on research and practice. Steinert Y ED. Springer, London 2014.
Steinert Y. Perspectives on faculty development 6/6 by 2020. Perspectives on medical education 2012; 1: 31–42
Challis M. AMEE medical education guide no. 19: Personal learning plans. Med Teach 2000; 22:225–36
Su-Ting LT, Paterniti DA, Co JPT, West DC. Successful Self-Directed Lifelong Learning in Medicine: A Conceptual Model Derived From Qualitative Analysis of a National Survey of Pediatric Residents. Academic Medicine, vol 85. No 7/July 2010
van Houten-Schat MA, Berkhout JJ, van Dijk N, Endedijk MD, Jaarsma ADC, Diemers AD. Self-regulated learning in the clinical context: a systematic review. Med Educ. 2018 Oct;52(10):1008–1015.
Van Tartwijk J, Driessen EW. Portfolios for assessment and learning: AMEE Guide no. 45, Medical Teacher, 31:9, 790–801, 2009
Watling CJ, Lingard L. Toward meaningful evaluation of medical trainees: the influence of participants’ perceptions of the process. Adv in Health Sci Educ (2012) 17:183–194
Danish National Board of Health. 1998. The Danish National Board of Health. (1998) Guidance and evaluation in the training of specialists in Denmark (DNBH Publications). In Danish.
Sambunjak D. Understanding wider environmental influences on mentoring: towards an ecological model of mentoring in academic medicine. Acta Med Acad 2015;44:47–57.
Act on Research Ethics Review of Health Research Projects | National Committee on Health Research Ethics – nvk.dk

Due to technical limitations, table 1 is only available as a download in the Supplemental Files section.

No competing interests reported.

Table1.png
Table 1: Main findings of the group of successes and non-successes on content, consequences, facilitators and barriers to appraisal meetings organized according to the SCM buckets and the themes emerging in the analysis.

PDF

Journal Publication

published 22 Apr, 2022

Read the published version in BMC Medical Education →

Editorial decision: Major revision
25 Nov, 2021
Reviews received at journal
20 Sep, 2021
Reviewers agreed at journal
09 Sep, 2021
Reviews received at journal
24 Aug, 2021
Reviewers agreed at journal
23 Aug, 2021
Reviewers invited by journal
23 Aug, 2021
Editor assigned by journal
23 Aug, 2021
Editor invited by journal
17 Aug, 2021
Submission checks completed at journal
17 Aug, 2021
First submitted to journal
12 May, 2021

You are reading this latest preprint version

What Works in Appraisal Meetings for Newly Graduated Doctors? – and What doesn't ?

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Methods

Step 1: Survey

Step 2: Interviews

Results

What was used?

What results were achieved?

What good did it do?

What helped?

What were the barriers?

Discussion

Longer appraisal meetings

A contact person – personal relations

An introduction to purpose and process

Help in using the learning plan

Career guidance

Limitations and generalizability

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors´contributions

Acknowledgements

References

Table

Competing Interests

Supplementary Files

Status:

Journal Publication

Version 1