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From the Nucleus for Teaching and Research in Medical Education, Department of Anesthesiology, Hospital Governador Celso Ramos, Florianópolis, SC, Brazil.
Address correspondence and reprint requests to Getúlio R de Oliveira Filho, MD., Rua Luiz Delfino 111/902 – 88015-360 – Florianópolis – SC – Brazil. Address e-mail to grof{at}th.com.br.
Abstract
The perceived relevance of the subject matter is an essential condition for adult learning. Attitudes refer to internal states that influence learner's choices of personal action, which determine the probability of learning behaviors. Our objectives in this study were to describe and compare attitudes of residents and anesthesiologists towards the relevance of basic sciences to clinical practice. An 8-item questionnaire was given to 105 residents and 142 anesthesiologists. Data were electronically collected. Responses were graded on 5-level Likert scales. Comparisons were made between responses of residents and anesthesiologists. Although a general pattern of acknowledged relevance of basic sciences to clinical practice was observed in both groups, anesthesiologists' ratings were significantly higher than residents' ratings. Both groups emphasized in-depth formal learning of basic sciences before their clinical application, but attending anesthesiologists' scores were significantly higher than residents' scores. Residents were more favorable to a more superficial approach represented by learning general concepts than anesthesiologists, although median scores were below the center of the scale (neutral). In both groups median ratings of the role of instructors in exciting residents' curiosity through the teaching of basic sciences were located in the center of the respective scales. Both groups rated their in-training educational experiences high.
Knowledge of basic sciences is assumed as essential to the practice of anesthesiology (1). The Accreditation Council for Graduate Medical Education requires didactic instruction during residency to include related areas of basic sciences, for which objective measures of achievement must be implemented to reliably demonstrate acquisition of knowledge (2). In Brazil, the curricular content on basic sciences is dictated by the Brazilian Society of Anesthesiology and includes anatomy, physiology, biochemistry, pharmacology, and physics as applied to clinical anesthesiology. Residents are exposed to such content during the first year of residency. In addition, topics on clinical anesthesiology addressed during the second and third years include reviews of the pertinent pathophysiological mechanisms.
The clinical application of physiology and pharmacology has been among the most frequently cited reasons for selecting anesthesiology as a career (3–5). However, during residency, trainees are exposed to many patients, drugs, procedures, and clinical scenarios long before formal instruction is completed. In this context, other approaches to knowledge acquisition may have to be used, including informal learning, which is primarily driven by the need to solve real problems and addresses the acquisition of small pieces of superficial knowledge just enough to immediate application (6). Furthermore, residents must acquire procedural skills early in training (7), a need that may eventually divert the focus of learning from the theoretical bases of clinical practice. In fact, it has been shown that proficiency in motor skills is achieved earlier in training than knowledge on underlying mechanisms and clinical management of spinal anesthesia (8). There is a paucity of data regarding the acquisition of basic science knowledge during the residency in anesthesiology. However, it has been shown that surgical residents' knowledge of basic sciences progresses at a significantly slower rate than knowledge of clinical aspects of surgery, so that little basic science knowledge is gained during residency (9).
The main purpose of this study was to describe the attitudes of medical anesthesia providers towards the relevance of basic sciences to clinical practice, the preferred approach to acquiring knowledge on basic sciences, and the perceived value of their educational experiences. As significant discrepancies have been reported when comparing resident and faculty responses to surveys on learning issues (10–13), we hypothesized that fully trained anesthesiologists might differ from residents with respect to the constructs under investigation. For this reason, comparisons between attitudes of anesthesia residents and attending anesthesiologists were planned a priori.
METHODS
The instrument used in the study was a modified version of the nine-item questionnaire developed by West et al. (14). Wording was adapted to our sample of attending anesthesiologists and anesthesia residents, by replacing "student" with "resident," "physician" with "anesthesiologist," and "faculty member" with "instructor." Item 3 ("psychological factors are just as important as physical factors in the healing process") was deleted, as it was not directly related to basic sciences (15).
The questionnaire comprised 8 items:
The questionnaire is a consistent instrument for descriptive purposes. Similar results obtained in different populations suggest high construct and face validities (15,16). Each item in the questionnaire is rated on a 5-level Likert scale (5 = strongly agree; 1 = strongly disagree). Agreement with items 3 and 4 and disagreement with items 1 and 2 reflect a general attitude of acknowledged relevance of basic sciences to the practicing anesthesiologist. Item 5 states the emphasis on separating formal learning of basic concepts from clinical application. Item 6 reflects preference for a more flexible approach to learning basic sciences, focused on the acquisition of operational concepts. The degree of agreement with these items indicates the degree of acceptance of the educational method to which the individual is being, or has been, exposed during residency. Items 7 and 8 measure the perceived value of respondents' educational experiences to date (14).
In previous studies (15,16), the ratio between mean differences across items in the questionnaire and mean standard deviation varied between 0.23 and 0.73, with a mean value of 0.46. For detecting a 0.46 sd difference between means, it was estimated that 75 respondents per group would be necessary, assuming 
= 0.05 and ß = 0.2. Surveys of similar populations have had response rates between 34% (3) and 72% (4). Assuming the smallest response rate, it was decided that at least 220 potential participants should have to be contacted in each category (residents and anesthesiologists), for obtaining samples of at least 100 respondents per category.
For constructing the study samples, 2 e-mail lists were created, including 750 board-certified anesthesiologists and 500 residents with available electronic addresses in the homepage of the Brazilian Society of Anesthesiology (www.sba.com.br). Randomization was obtained by electronic random number generation. Lists were classified in ascending order of random numbers. The study sample included the initial 220 electronic addresses in both anesthesiologist and resident lists. Invitations to participate were made by e-mail messages that contained a link to the questionnaire website. Undelivered messages were replaced with consecutive addresses until the pre-established number of messages was achieved. Two reminders were delivered at 2-wk intervals. Data collection was interrupted 2 wk after the last reminder and comprised the period from August through November 2004.
An electronic form was constructed on FrontPage 2000 (Microsoft, Redmond, WA). For the purposes of the study, basic sciences were defined as the curricular content of anatomy, physiology, biochemistry, pharmacology, and physics to which respondents were being, or had been, exposed during the residency. Respondents were informed of this operational definition.
Response rates were calculated for residents and anesthesiologists. Each statement in the questionnaire was considered a dependent variable, measured on a 5-point Likert scale, as outlined above. We hypothesized that responses of anesthesiologists and residents to the items in the questionnaire would follow different patterns (distribution of Likert scale levels), characterizing different underlying metrics. As we intended to compare median scores of both populations, we first converted the ordinal scales in which the responses were captured into interval scales. Correspondence analysis was used to re-scale the Likert scores from ordinal to interval data. This was done by calculating the Euclidean distances between scale points on the first two axes and apportioning these distances to re-calculate numerical values of the scale points between 1 and 5 for the 5-point Likert scale. Bendixen and Sandler (17) have clearly documented this procedure, which is essential for statistical manipulation and interpretation of the raw data. The conversion of the Likert scale was performed separately for each category of raters on each item of the questionnaire. The coordinates of the two axes (x and y) and their Eigen values were used for computing the Euclidean distances, which were re-spread proportionately to fit the intervals between the first and last Likert points used (i.e., 3 intervals for 5-point Likert scales). Successive (cumulative) additions of the intervals to the first point of the Likert scale established the re-scaled Likert points, which were then used in computations. Linear regression between the original Likert scores and the re-scaled scores (levels 2 through 4) was applied, and the slopes of the resulting lines were compared as a measure of metric equivalence between residents' and anesthesiologists' re-scaled scores.
Data were analyzed by Mann-Whitney U-test for 2 independent groups (residents and attending anesthesiologists). Spearman R coefficients were calculated between age of respondents and the respective ratings on each item to test whether there were significant associations between age (as a surrogate for years in practice) and attitudes towards basic sciences. As 8 independent tests were performed, a more stringent criterion of P < 0.01 for significance was used (16).
RESULTS
One-hundred-five residents (48%) and 142 anesthesiologists (65%) completed the questionnaire. The overall response rate was 56%. Respondents were classified in 6 groups: G1: first-year residents (n = 34; 14%); G2: second-year residents (n = 55; 22%); G3: third-year residents (n = 16; 6%); G4: attending anesthesiologists involved in training (n = 67; 27%); G5: program directors (n = 33; 13%); and G6: attending anesthesiologists not involved in training (n = 42; 17%). Male/female ratios were 72/33 among residents and 112/30 among attending anesthesiologists. Age varied between 24 and 68 yr (mean ± sd = 37.27 ± 11.72 yr).
Figure 1 shows responses of residents and attending anesthesiologists to items of the questionnaire. Although a general pattern of acknowledged relevance of basic sciences to clinical practice was observed in both groups, anesthesiologists' ratings were significantly higher than residents' in items 3 and 4. Although both groups emphasized in-depth formal learning of basic sciences before their clinical application (item 5), attending anesthesiologists' scores were significantly higher than residents'. Residents were more favorable to a more superficial approach represented by learning general concepts than anesthesiologists (item 6), although median scores were below the center of the scale (neutral). In both groups median ratings of the role of instructors in exciting residents' curiosity through the teaching of basic sciences were located in the center of the respective scales (item 7). Both groups rated the perceived value of their in-training educational experiences high (item 8).
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Age of the respondent correlated significantly (P < 0.01) with scores on items 2 (r = 0.31), 3 (r = 0.37), 4 (r = 0.44), 5 (r = 0.33), 6 (r = –0.26), and 8 (r = –0.26).
Figure 2 shows the graphic analysis of metric equivalence between attending anesthesiologists' and residents' ratings on items of the questionnaire. Significant differences in slopes of the re-scaled items were found in plots of items 7 and 8, indicating absence of scalar equivalence between groups.
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DISCUSSION
The pattern of responses obtained in this study suggests that, in general, residents and anesthesiologists acknowledge the relevance of basic sciences to the practice of anesthesia, as suggested by the predominant disagreement (low ratings) with items 1 and 2 and agreement (high ratings) with items 3 and 4 (14). Accordingly, both trainees and attending anesthesiologists acknowledge that an anesthesiologist cannot effectively treat most clinical problems without a detailed knowledge of underlying biological processes; that basic sciences are attached to, and useful for, the practice of anesthesiology; that knowledge of biological mechanisms is one important feature of a good anesthesiologist; and that residency should emphasize the application of basic sciences to clinical practice. Such attitudes are in accordance with previous studies, in which the opportunity for clinical application of basic sciences, specifically physiology and pharmacology, has strongly influenced the choice of anesthesiology as a career (3–5).
This study has also shown that both residents and anesthesiologists share a preference for a more traditional approach to learning basic sciences (item 5). This finding might reflect the formal structure of the curricular content to which anesthesia residents are exposed in Brazil. However, residents rated item 6 higher than attending anesthesiologists; this item addresses a more flexible approach to learning, a characteristic of integrative curricula and learner-centered teaching methods (18).
Such attitudinal differences are further suggested by the significant positive correlation between age and ratings to item 5 and the negative correlation between age and item 6. In other words, attending anesthesiologists preferred learning strategies of conventional teaching, whereas residents approached learning in a more flexible format. Conventional teaching assumes the acquisition of knowledge before clinical application. Acquisition of factual knowledge is based primarily on rote memorization of detailed scientific facts, for which applicability to clinical practice is not immediately demonstrable. Acquisition of operational concepts refers to the construction of a knowledge base directed to fulfill the need of explaining and managing clinical scenarios, an approach widely used in problem-based learning, and commonly adopted by practicing physicians when faced with real patients' problems (6). Because operational concepts are primarily constructed on the basis of individual learning needs, it is not clear how deep they are. Although problem-based learning emphasizes the construction of operational concepts of basic sciences applied to clinical scenarios (14–16), evidence of learning and patient outcomes are still lacking.
Another finding of this study was that no predominant pattern was observed regarding the role of instructors in exciting resident's curiosity about basic sciences, as demonstrated by median scores around the center of the scales of item 7. In previous studies, students in innovative curricula have consistently rated this item more positively than did those in conventional teaching, a finding that has been interpreted as resultant of the contribution of enthusiastic tutors serving as role models to students and of the close interaction between residents and tutors during clinical experiences (15,16). Our data cannot explain this finding, but it might signal a certain lack of enthusiasm of faculty in addressing issues of basic sciences during their contact with residents (19).
Data were collected on an electronic form, via the Internet. Internet surveys of health professionals provide rapid access to a large number of individuals, fast gathering of data, and considerable cost savings. However, external validity of findings and response rates may be threatened by several sources of error. Sampling error may occur when only a portion of the target population is included; coverage error may arise when some units of the target population are excluded or disproportionately included; measurement errors may occur as a consequence of survey format, browser characteristics, situational variables, and characteristics of the respondents; and non-response error, which occurs when only a portion of the sample completes the survey. Factors influencing response rates include the sensitive nature of questions, unwillingness to participate, lack of interest in the subject, or unreliance on the confidentiality of responses. Moreover, anti-spam software may block messages having links to homepages such that the target population is decreased. Indeed, small response rates have been reported by authors who used the Internet for collecting data (20,21). These sources of errors may be minimized by carefully wording sensitive questions, assuring confidentiality, establishing anonymity of participants, using reminders, and using e-mail lists consisting of persons with common interests that voluntarily provide their electronic addresses (21).To cope with these problems and limitations, we followed the above-mentioned recommendations and followed standard random sampling procedures. However, our sample consisted of anesthesiologists and residents who had e-mail addresses on file with the Brazilian Society of Anesthesiology. This sampling comprises individuals more likely to be technophiles, and hence more interested in basic science, than anesthesiologists without e-mail addresses; individuals more likely to be compulsive than those who did not file their e-mail addresses, which might be expected to positively associate with reading the medical literature; and/or anesthesiologists and residents who actually read and respond to e-mail requests to participate in a survey, and who may similarly be predisposed to an interest in science. Such sources of sampling biases must be considered when interpreting or generalizing our results. Caution must also be exercised when interpreting comparisons between residents and attending anesthesiologists for responses to items 7 and 8. No scalar equivalence could be demonstrated across groups, indicating that each category interpreted and reacted to these items differently (22).
A number of studies have assessed the effectiveness of strategies designed to improve attitudes towards basic sciences. It has been demonstrated that the integration of basic sciences into clinical context improves attitudes of medical students to basic sciences during the preclinical years (14–16). Residents are fully exposed to clinical scenarios that provide a great diversity of opportunities for integrating basic sciences into clinical practice. Specific interdisciplinary learning activities, followed by assessment and feedback, have worked in providing knowledge about the continuum from clinical to basic sciences for both senior medical and PhD students (23,24). Problem-based learning has also been demonstrated to improve attitudes to the relevance of basic sciences to clinical practice (16). It has been suggested that journal clubs addressing basic sciences topics could foster learning. Developing reading strategies on basic sciences articles has been shown to improve learning and reading (25).
In conclusion, although both residents and attending anesthesiologists demonstrated a general attitude of acknowledged relevance of basic sciences to clinical practice, time in practice was associated with stronger attitudes towards this construct. Both residents and anesthesiologists valued a formal approach to learning basic sciences, which implies first acquiring basic knowledge before application into real clinical scenarios. Again, time in practice was associated with stronger attitudes towards this construct. Conversely, residents were also likely to accept a knowledge base constructed of more general, operational concepts on basic sciences, which was negatively correlated with time in practice. Finally, both residents and anesthesiologists acknowledged the value of the residency training for their professional life, but were not sure of the role of faculty in stimulating the learning of basic sciences during the residency. Whether and/or how such attitudes influence the development of professional competence and patient outcomes remains to be studied.
Footnotes
Accepted for publication February 27, 2006.
REFERENCES
This article has been cited by other articles:
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  G. R. de Oliveira Filho and J. E. Vieira The Relationship of Learning Environment, Quality of Life, and Study Strategies Measures to Anesthesiology Resident Academic Performance Anesth. Analg., June 1, 2007; 104(6): 1467 - 1472. [Abstract] [Full Text] [PDF]
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