Educational climate of a pathology residency program at a tertiary care hospital

RESEARCH ARTICLE Educational climate of a pathology residency program at a tertiary care hospital Zafar AliID1, Hashaam Bin Ghafoor2, Muhammad Nasir Ayub Khan3, Muslim Atiq4, Saira AkhlaqID5* 1 Division of Pathology, Department of Histopathology, Shifa International Hospital, Islamabad, Pakistan, 2 Department of Anaesthesia, Al-Khor Hospital, Hammad Medical Corporation, Doha, Qatar, 3 Department of Anaesthesia, Shifa International Hospital, Islamabad, Pakistan, 4 Department of Gastroenterology, Shifa International Hospital, Islamabad, Pakistan, 5 Master’s in Health Professions Education, Shifa School of Health Professions Education, Shifa Tameer-e-Millat University, Islamabad, Pakistan * saira.sshpe@stmu.edu.pk Abstract Evaluating educational climate (EC) is imperative for ensuring postgraduate trainees’ com- petencies and quality in residency training programs. This study assessed the EC experi- ences of pathology postgraduate residents (PGRs) during their postgraduate training in pathology residency programs—a cross-sectional study design assigned EC scores in the pathology residency program at a prestigious institution in Islamabad, which were measured using the Dutch Residency Educational Climate Test (D-RECT) questionnaire. Scores from the D-RECT were employed to conduct descriptive statistics and comparison of means across groups to evaluate EC scores by years of training and compared to assess where the differences were located. Among FCPS-II pathology residents, most of whom were females (94.4%), the mean age was 28.11±2.91 years. A mean positive score was observed

among all pathology residents (M�3.6) for all D-RECT subscales except for the feedback subscale: the average score for feedback was below the average mean score of 3.6 (M = 3.19). A significant difference p = 0.016 was observed in EC scores across different groups through the Analysis of Variances (ANOVA) test. The most significant difference was between less than two and greater than two groups p = 0.027, followed by the difference between equal to two groups and greater than two groups p = 0.052. Overall, positive scores for EC in the pathology residency program were observed. Thus, targeted interventions are needed to increase feedback scores and address observed differences in EC scores by years of training. Introduction Educational Climate (EC) is the pivot around which the other four focal areas of medical edu- cation (i.e., Curriculum, Environment, Quality, and Change) are considered for discussion [1]. Educational Environment (EE) may be described as an environment that is influenced by the physical environment (i.e., safety, comfort, food), emotional environment (i.e., feedback qual- ity and security), and educational environment (i.e., participation, relevance, and education PLOS ONE PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 1 / 10 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Ali Z, Ghafoor HB, Ayub Khan MN, Atiq M, Akhlaq S (2024) Educational climate of a pathology residency program at a tertiary care hospital. PLoS ONE 19(5): e0303534. https://doi.org/10.1371/ journal.pone.0303534

Editor: Ritesh G. Menezes, Imam Abdulrahman Bin Faisal University, SAUDI ARABIA Received: August 21, 2023 Accepted: April 26, 2024 Published: May 23, 2024 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0303534 Copyright: © 2024 Ali et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: Data has been attached as a Supporting Information file. Funding: The author(s) received no specific funding for this work.

planning) [2, 3]. Experiences within an EC are directly or indirectly linked with the valuable outcomes of student achievement, satisfaction, and success [1]. During postgraduate (PG) train- ing programs, EC is an essential marker for quality in PG medical education [4–6], and the suc- cessful translation of a curriculum in EE depends upon an adequate EC [7–9]. Enhancing the latter in medical education also depends upon establishing a continuous feedback system, espe- cially among emerging nations and new training institutions [9]. Henceforth, establishing a feedback system in EC of a histopathology residency program is necessary to achieve positive outcomes through an EE that improves learning [7–9], the well-being of PGRs [10–12], profes- sionalism [13], learning satisfaction [14], and competency of health care professionals (HCP) [9]. The EC of PG programs highlights the environment in which PGRs learn about the context and shared identification of approaches, techniques, and practices [15]. In comparison, achieve- ment of excellence through PGRs’ training program may be influenced by obtrusive clinical EE that may lead to fatigue, exhaustion, and burnout among PGRs, leading to dropout [16]. Measuring the learning environment (LE) offers a reference point for the didactic institu- tion [17]. The measurement process facilitates answering trainers’ and trainees’ questions about the learning experience’s quality. The pathology training program is considered distinc- tive because a deficiency is observed in the exposure to several lab sections during house job

and MBBS. The pathology residency program is divided into subspecialties such as Chemistry, Histopathology, Immunology, Hematology, and Microbiology; each sub-specialty has its unique EC. To fulfill the increasing demand for pathology training, valuable programs are needed on a large scale as any change or development induces recognition of the available teaching models, boosts PGRs’ education, and enhances their experience. The pathology grad- uates and employers agree that existing pathology residency training remains inadequate in preparing the residents who are competent in clinical chemistry during their professional careers primarily due to less value placed by residents on learning clinical chemistry and the lack of directors who supervise and manage labs of clinical chemistry [18]. The impassiveness of the teaching staff or residents is an essential obstruction in teaching clinical chemistry to the residents [18]. As explained by residents, unsupportive EE and abortive teaching techniques are the main drawbacks [18]. EC using D-RECT has been assessed in various local and international studies [19]. How- ever, these studies involved different disciplines [3, 19–21], and the nature of EC depends upon the nature of the setting, i.e., each unique specialty and sub-specialty [1, 18, 22, 23]. The current study, therefore, assessed the EC of a PG pathology residency program by administer- ing D-RECT and was conducted considering the need for future research in more focused areas by examining the individual disciplines to increase the likelihood of ruling out subject-

specific differences [24], mainly when the same climate index can be used even with different stakeholders [7]. Materials and methods A cross-sectional study design approved by the ethics committee of Shifa Tameer-e-Millat University was used at Shifa International Hospital (Islamabad, Pakistan) to assess EC scores of pathology residents by years of training. Enrollment in the study required voluntarily informed permission from participants (including all voluntary pathology PGRs), which was acquired through written consent following the Shifa International Hospital Protocol. Data was collected from 06/06/2021-06/30/2021. During this period, the D-RECT instrument (fifty items categorized into eleven subscales) was used to evaluate EC scores among trainees, and demographic data variables like age, sex, specialist area, and years of training were acquired in the data collection process. PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 2 / 10 Competing interests: The authors have declared that no competing interests exist.

Data was collected through a paper-format questionnaire stored in locked folders for data safety and security, and paper-format data was converted into electronic files using SPSS 21.0. The mean of the D-RECT ranking and each subscale were determined as follows: the descrip- tive data analysis included the calculation of Mean (M), Standard Deviation (SD), frequency (f), and percentages (%) and an average score below 3.6 was considered a negative perception in any subscale. Results The response rate was 100% (18). Refer to data in S1 Dataset for complete access to data that was used in the data analysis. Considering the age categories of more than and less than 30 years old, 83.3% (15) of the study participants were �30 years, and only 16.7% (3) were >30 years. The average age was 28.11±2.908 years, and PGRs included more females (94.4%) than males (5.6%). PGRs in the first two years of training were more significant in numbers (66.6%) than those PGRs in the last three years (33.4%). The histopathology department had the high- est number of PGRs, 55.5% (10), while 33.6% (6), 5.6% (1), and 5.6% (1) were working in the hematology, immunology, and chemical pathology department, respectively. Overall, positive experiences (M = >3.6) were reflected in EC of the pathology residency program as measured through the sub-scales on the D-RECT questionnaire, except Subscale: feedback (M�3.6) in Table 1. Comparison of means ANOVA. Data for the overall EC scores was typically distributed as the overall p>0.05.

Please refer to the Table in S1 Table for assessing the test of normality that was used to deter- mine the normality of data. An overall summary of the mean scores of EC across three differ- ent groups was calculated. There were fewer participants in the created Groups 4 and 5. Therefore, Groups 4 and 5 were added to Group 3 because only one participant was in Groups 4 and 5. There were equal participants in the final groups, i.e., Group 1 (less than 2), Group 2 (equal to 2), and Group 3 (greater than 2). A category “less than 2” refers to PGRs in the 1st year. The “Equal to 2” category refers to PGRs in the second year, and the “greater than 2” cate- gory refers to PGRs in the 3rd, 4th, and 5th years. A summary of means across different groups is as follows in Table 2. Table 1. Descriptive statistics for educational climate (D-RECT subscales). Subscales Perspective Mean±SD Agree Neutral Disagree Supervision 17 (94.4%) 1 (5.6%) 0 (0%) 4.56±0.457 Coaching and assessment 18 (100%) 0 (0%) 0 (0%) 4.45±0.429 Feedback 8 (44.4%) 10 (55.6%) 0 (0%) 3.19±0.458 Teamwork 18 (100%) 0 (0%) 0 (0%) 4.43±0.427 Peer collaboration 17 (94.4%) 1 (5.6%) 0 (0%) 4.54±0.606 Professional relations between attending 18 (100%) 0 (0%) 0 (0%) 4.41±0.465 Work is adapted to residents’ competence 18 (100%) 0 (0%) 0 (0%) 4.10±0.536 Attendings’ role 18 (100%) 0 (0%) 0 (0%) 4.58±0.506 Formal education 18 (100%) 0 (0%) 0 (0%) 4.19±0.504 Specialty Tutor’s role 18 (100%) 0 (0%) 0 (0%) 4.37±0.497 Patients sign out 18 (100%) 0 (0%) 0 (0%) 4.22±0.535

Overall D-RECT 18 (100%) 0 (0%) 0 (0%) 4.39±0.385 https://doi.org/10.1371/journal.pone.0303534.t001 PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 3 / 10

One-way ANOVA was conducted to identify if there were any differences between and within groups. A significant difference was observed in the LC scores across different groups, p = .016 in Table 3. Multiple comparisons. After observing the ANOVA analysis, multiple comparisons were conducted to identify where the difference was located, highlighted between 1st year of pathol- ogy and 3rd year of residency and above, and it was similarly observed between 2nd year of the pathology residency program and 3rd year of residency and above in LC scores in Table 4. Discussion EC is a crucial variable that must be monitored to guarantee the caliber of instruction in a healthcare setting that offers an EE for PGR training. Most PGRs in the pathology residency program were females (83.3%) and �30 years old; generally, numerous study participants (66.6%) were from the first and second years of the pathology residency program. Considering the subscales on the D-RECT, each may be considered a separate variable or domain for understanding purposes to discuss their unique implications. Additionally, Table 2. Descriptive of variances in EC scores across groups. Descriptive Total LC Scores N Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound Less than 2 6 4.59 .455 .186 4.12 5.07 4 5 Equal to 2 6 4.53 .273 .112 4.24 4.82 4 5 Greater than 2 6 4.05 .088 .036 3.95 4.14 4 4 Total 18 4.39 .385 .091 4.20 4.58 4 5 https://doi.org/10.1371/journal.pone.0303534.t002

Table 3. ANOVA-variations in EC scores by groups. Total LC Scores Sum of Squares df Mean Square F Sig. Between Groups 1.073 2 .536 5.557 .016a Within Groups 1.448 15 .097 Total 2.521 17 aThe mean difference is significant at the level of 0.05. https://doi.org/10.1371/journal.pone.0303534.t003 Table 4. Multiple comparisons. Dependent Variable: Total EC scores (I) Years (J) Years Mean Difference (I-J) Std. Error Sig. 95% Confidence Interval Lower Bound Upper Bound Less than 2 Equal to 2 .063 .179 .940 -.42 .55 Greater than 2 .547a .179 .027 .06 1.03 Equal to 2 Greater than 2 .483b .179 .052 .00 .97 aThe mean difference is significant at the 0.05 level. bThe mean difference is significant at the 0.05 level. https://doi.org/10.1371/journal.pone.0303534.t004 PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 4 / 10

supervision is one such sub-scale that is an essential component of any training program. The need to supervise pathology residents constantly by hospital teaching staff is always to provide patients with safe, effective, and better-quality care. PGRs score for supervision were high (average score 4.56 +/- 0.457) in a large percentage (94.4%) of study participants, which were comparatively better than the scores (3.75 +/- 1.49) among PGR residents from multiple spe- cialties [20] and during shift change (3.93 +/- 0.36) in a study conducted in the Netherlands that included residents from multiple specialty training programs during shift change [15]. Despite the prevalence of positive perceptions with varying degrees of magnitude in different populations, negative perceptions have also been observed in some studies, specifically about supervision (2.83 +/- 0.83) [4] and in residents of the Saudi emergency department in Riyadh (3.30 +/- 1.17) [23]. Therefore, identifying mechanisms that nurture differences in the magni- tude of positive scores and factors/strategies that lead to lower scores for supervision may help address the weaknesses within the educational systems and facilitate building on the strengths of a solid educational system by using it as a model. Coaching and assessment play a vital role that can never be overlooked. A positive percep- tion of coaching and assessment was prevalent (4.45 +/- 0.429) among study participants (100%), like positive perceptions (3.92 +/- 0.32) observed in medical residents in the Philip-

pines [25]. Despite the prevalence of positive scores in the current study and another study in the literature, there are still some studies that report lower scores (2.60 +/- 0.73, 3.24 +/- 0.35, and 3.08 +/- 1.17) in Saudi psychiatry residents, 45 multi-specialty residents in the Nether- lands, and Saudi Emergency residents correspondingly for perceptions about coaching and assessment [4, 15, 23]. Therefore, future studies may identify and compare the factors leading to these scores’ differences. Such an approach may help adopt mechanisms associated with higher scores for coaching and assessment. Feedback is a significant factor that enhances pathology residents’ learning process in three ways: it updates learners regarding their deficiency/progress, advises learners regarding observed training needs and resources available, assists them during learning, and encourages learners to engage in adequate learning activities. Despite the well-established understanding of the effectiveness of feedback in learning outcomes if communicated appropriately, feedback scores reportedly had been on the lower end [4, 15, 20]. A negative perception about feedback (3.19 +/- 0.458) in the current study re-affirms the previous findings about the low scores for feedback (2.00 +/- 0.85, 3.24 +/- 0.45 and 2.75 +/- 0.54), respectively [4, 15, 20]. The observed trend reflects the need for further concentration in the focused area of feedback to improve the patient-care capacity of the PGRs. Additionally, significant differences in means of EC scores

by years of training signal a need to identify differential pathways through which these differ- ences in means occur. For example, even in the low feedback scores range, lower scores were slightly higher for a single specialty but at multiple sites; perhaps, it could justify the slightly better feedback scores when considering the collective assessment of scores across all special- ties of medicine for PG training, even though scores were still lower, i.e., less than 4 (3.75 +/- 1.49) [20]. Similarly, feedback scores remain lower even when the primary purpose is not to measure the feedback scores but to measure feedback scores for assessing their effect. For example, the effect of LE on faculty’s teaching performance is assessed by residents’ perceptions (3.24 +/-0.45) [15]. When considering feedback scores for each item, it appears that the scores for the generalized feedback to residents are comparatively better (2.80+/-1.18) than the ones from a structured format (2.36+/-1.19) even though the feedback provided through the latter is more regular (2.39+/-1.22), despite the scores remaining consistently lower, i.e., below 4 in any of the three reported ways to provide feedback [23]. Thus, future research studies may uti- lize these findings and focus more on the needed forms of feedback, like structured rather than PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 5 / 10

generalized feedback, and identifying mechanisms that nurture the promotion of structured feedback within the educational systems, facilitating the building of a feedback system in edu- cational settings by using this proposed design as a model. This development and implementa- tion of interventions based on conceptual models can be used to improve feedback communication and interpretation to PGRs, requiring the integration of evidence-based methodologies to disseminate structured feedback upon which the learner can reflect. For PGRs learning, teamwork is considered a significant tool that assists in modifying learners’ attitudes and increases their efficiency, yet perceptions about teamwork have been reported differently in literature. In the present study, they are mainly positive (4.43 +/- 0.427), as well as in a study of Saudi emergency residents in Riyadh (4.05 +/- 0.97) [23], while the prevalence of negative ones (2.81 +/- 0.86) has been reported in Saudi psychiatry residents [4]. A large majority of study participants (94.4%) reported high scores for peer collaboration (4.54 +/- 0.606), consistent with the numbers in the literature, i.e., 82% of study participants reported positive perception (4.07 +/- 2.02) in a study of residents from different disciplines in Army Medical Hospital of Rawalpindi, Pakistan [20]. A low score for perceptions regarding peer collaboration was reported in a French population where the score was less than 3.6 (3.54 +/- 0.90) [26], though almost close to 3.6. It may be inferred from the differential prevalence

levels for scores indicating teamwork that future interventions may be planned and imple- mented to enhance teamwork among PGRs. A positive perception of professional relations among the attendings (4.45 +/- 0.429) was found among all the participants (100%), like high positive perception scores (3.61 +/- 0.67) in a study where students evaluated the effect of learning climate on the faculty’s teaching perfor- mance [15], and in contrary to the finding in psychiatry residents where negative perceptions (2.71 +/- 0.95) were prevalent [4]. Work is adapted to the residents’ competence (4.10 +/- 0.536) was positively perceived among all the pathology residents (100%), despite controversial findings in literature where this variable has been perceived positively (4.06 +/- 0.28) in a study among internal medicine residents in the Philippines [25] and negatively perceived in another study of residents from medical and allied sciences training as well as surgery and allied sci- ences PGR training of one institution in Pakistan [20]. Perceptions about “Professional rela- tions between the attendings” and “Work adapted to the residents’ competence” are two variables that may or may not impact the quality of EC in any healthcare sector. Therefore, consistent efforts should be made to improve the scores for these variables. Consultants play a vital role in developing positive perceptions about EC amongst residents. A positive perception regarding them (4.58 +/- 0.506) was prevalent among residents (100%);

the finding coheres with positive perception (above 3.6) [15] and is contrary to the findings in a study among Saudi psychiatry residents where negative perception prevailed among resi- dents regarding consultant’s role (2.71+/-0.86) [4]. An overall trend of positive experiences was observed amongst 100% of pathology residents regarding formal education (4.19±0.504), like a positive perception regarding formal education (M = >3.6) amongst residents from mul- tiple PGR training programs in Pakistan [20]. Thus, whether it is the active role of consultants or formal education, consultants may be viewed within the context of formal education; this would help enhance the capacity of consultants in formal education. The role of teachers can never be underestimated in improving the EC, while successful learning could be attained through the active role of specialty teachers. A positive perception (4.37+/-0.497) for the specialty tutor role was prevalent for 100% of participants, like positive perception (3.83 +/- 0.32) in a validity assessment of the D-RECT tool in a non-westernized context [25]. Despite reporting positive perceptions in different studies, negative perceptions (3.21 +/- 1.02) have also been reported in a study that focused not on a single specialty but mul- tiple specialties [20], resulting in the need for further exploration of specialty teachers’ roles. PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 6 / 10

Views about patient sign-out are essential as a variable because residents’ perceptions could improve with an upgraded patient sign-out system. This consideration sparked because of high scores for patients signing out (4.22±0.535) among residents (100%), like the positive scores (3.82 +/- 0.46) during a shift change in a study in the Netherlands that included resi- dents from multiple specialty training programs [15]. Nevertheless, scores in the current study were higher, indicating a positive impact on our patient sign-out system. Despite consistent positive findings in the literature about patient sign-out, negative perception has also been reported (3.50±1.15) when patient sign-out across multiple specialties was done and could reduce the representative size from each specialty [20]. These differential findings provide evi- dence for further improvement of patient-sign-out systems in specific settings. Overall, a positive perception (>3.6) about EC Subscales of the D-RECT questionnaire was found in almost all the PGRs working in the four departments (histopathology, chemical pathology, immunology, hematology) of the pathology residency program. A positive percep- tion regarding the overall EC score (4.39+0.385) was observed, which corresponded to the overall positive score for clinical learning (3.85 +/- 0.29) in Filipino medical residents [25]. However, a negative perception regarding EC (3.16±0.92) has also been reported in a study of Moroccan residents where a French translation of the D-RECT scale was used for psychomet-

ric analysis of the tool’s French version [26]. Despite the positive score for EC, score variations by years of training p�0.05 were observed; it is supposed that they reflected changing percep- tions of PGRs about the attributes of EC due to the transition of PGRs into senior years. In var- ious years of training, different challenges and milestones may influence perceptions about experiences regarding LC. In senior years (from third to fifth), residents may feel added responsibility with low time availability for each commitment, relatively less supervised task performances, and the increased complexity of competencies that need to be mastered during the residency training [27]. Therefore, the observed differences in EC scores by years of train- ing may reflect that in the earlier years of residency, i.e., first year and second year, residents might be more enthusiastic about their professional futures and invest consistent time com- mitments for training milestones and adjust corresponding to relatively simple competencies to be mastered. Additionally, significant differences in means of EC scores by years of training in our study contradict the assessed differences in scores by years of training in an emergency department [23]. However, there are methodological differences in how the differences were calculated. In a study in the emergency department [23], scores were determined individually for each con- struct on the D-RECT and then compared by years of training. In addition, emergency resi-

dency training is only for four years. In our study, we calculated the average mean score for the overall D-RECT and then compared the scores by each year. Furthermore, in our study, the pathology residency program lasts five years. We condensed these years of training into three groups. We conducted ANOVA to assess if any significant differences could be identified in addition to a post-hoc analysis through multiple comparisons to see where differences were located, as identifying differences in perceptions about EC scores reflects a need to devise mechanisms to address these differences. A limitation of our study is that it included a smaller sample size. Enrolling any new PGRs for the study was impossible as these were the maximum PGRs during the study, and even though the study participants provided voluntary informed consent to participate, the response rate was 100%. To address the limitation of sampling size, this study may be consid- ered a pilot study and, in the future, may be replicated in the same setting but with a different study design, i.e., longitudinal study design. Our study’s strength is that it focuses on the pathology residency program. Considering the diverse needs of EC in each unique setting, it was essential to assess the needs within our EC. To achieve this milestone, a research study was PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 7 / 10

lead to these variations. Such an approach would help address the differences in EC scores by implementing targeted interventions. It is expected that feedback scores for pathology trainees can be improved by following the same approach. Supporting information S1 Dataset. Dataset used in this study. This is the data file for the data on EC scores in a pathology residency program at a tertiary care hospital. (CSV) S1 Table. Test of normality Kolmogorov-Smirnov. This is the table for the test of normality that was conducted to confirm if data was normally distributed. (DOCX) Acknowledgments The research study was initially conducted as a part of the master’s in health Professions Edu- cation (MHPE) Thesis at Shifa Tameer-e-Millat University. Author Contributions Conceptualization: Zafar Ali, Hashaam Bin Ghafoor, Muhammad Nasir Ayub Khan. Data curation: Zafar Ali, Saira Akhlaq. Formal analysis: Zafar Ali, Saira Akhlaq. Investigation: Zafar Ali. Methodology: Zafar Ali. Software: Zafar Ali, Saira Akhlaq. Supervision: Hashaam Bin Ghafoor, Muhammad Nasir Ayub Khan. Validation: Muslim Atiq. PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 8 / 10

Visualization: Zafar Ali. Writing – original draft: Zafar Ali. Writing – review & editing: Saira Akhlaq. References 1. Genn JM. AMEE Medical Education Guide No 23 (Part 1): Curriculum, environment, climate, quality and change in medical education-a unifying perspective. Medical teacher. 2001; 23: 337–44. https:// doi.org/10.1080/01421590120063330 PMID: 12098379 2. Altemani AH, Merghani TH. The quality of the educational environment in a medical college in Saudi Arabia. International journal of medical education. 2017; 8: 128. https://doi.org/10.5116/ijme.58ce.55d2 PMID: 28412724 3. Roff S, McAleer S. What is educational climate? Medical teacher. 2001; 23: 333–4. https://doi.org/10. 1080/01421590120063312 PMID: 12098377 4. Alshomrani AT, AlHadi AN. Learning environment of the Saudi psychiatry board training program. Saudi medical journal. 2017; 38(6): 629–35. https://doi.org/10.15537/smj.2017.6.18164 PMID: 28578443 5. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and bene- fits. New England journal of medicine. 2012; 366: 1051–6. https://doi.org/10.1056/NEJMsr1200117 PMID: 22356262 6. WFME. Postgraduate medical education: WFME global standards for quality improvement. Copenha- gen (DK): World Federation for Medical Education; 2003. 7. Bassaw B, Roff S, McAleer S, Roopnarinesingh S, De Lisle J, Teelucksingh S, et al. Students’ perspec- tives on the educational environment, Faculty of Medical Sciences, Trinidad. Medical teacher. 2003; 25: 522–6. https://doi.org/10.1080/0142159031000137409 PMID: 14522676

8. Genn JM. AMEE Medical Education Guide No. 23 (Part 2): Curriculum, environment, climate, quality and change in medical education—a unifying perspective. Medical teacher. 2001; 23: 445–54. https:// doi.org/10.1080/01421590120075661 PMID: 12098364 9. Roff S. The Dundee Ready Educational Environment Measure (DREEM)—a generic instrument for measuring students’ perceptions of undergraduate health professions curricula. Medical teacher. 2005; 27: 322–5. https://doi.org/10.1080/01421590500151054 PMID: 16024414 10. Hobgood C, Hevia A, Tamayo-Sarver JH, Weiner B, Riviello R. The influence of the causes and con- texts of medical errors on emergency medicine residents’ responses to their errors: an exploration. Aca- demic medicine. 2005; 80: 758–64. https://doi.org/10.1097/00001888-200508000-00012 PMID: 16043533 11. Mareiniss DP. Decreasing GME training stress to foster residents’ professionalism. Academic medi- cine. 2004; 79: 825–31. https://doi.org/10.1097/00001888-200409000-00003 PMID: 15326004 12. Tsai JC, Chen CS, Sun IF, Liu KM, Lai CS. Clinical learning environment measurement for medical trainees at transitions: relations with socio-cultural factors and mental distress. BMC medical education. 2014; 14: 226. https://doi.org/10.1186/1472-6920-14-226 PMID: 25335528 13. Brown J, Chapman T, Graham D. Becoming a new doctor: a learning or survival exercise? Medical edu- cation. 2007; 41: 653–60. https://doi.org/10.1111/j.1365-2929.2007.02785.x PMID: 17614885 14. Silkens ME, Arah OA, Scherpbier AJ, Heineman MJ, Lombarts KM. Focus on quality: investigating resi-

dents’ learning climate perceptions. Plos one. 2016; 11: e0147108. https://doi.org/10.1371/journal. pone.0147108 PMID: 26765742 15. Lombarts KM, Heineman MJ, Scherpbier AJ, Arah OA. Effect of the learning climate of residency pro- grams on faculty’s teaching performance as evaluated by residents. Plos one. 2014; 9: e86512. https:// doi.org/10.1371/journal.pone.0086512 PMID: 24489734 16. Yousaf MJ, Yasmeen R, Khan MA, Qamar K. Perceptions of postgraduate residents regarding clinical educational environment by using the post graduate hospital education environment measure (PHEEM) inventory. Pakistan Armed forces medical journal. 2017; 67(6): 914–18. 17. Maudsley RF. Role models and the learning environment: essential elements in effective medical edu- cation. Academic medicine. 2001; 76: 432–4. https://doi.org/10.1097/00001888-200105000-00011 PMID: 11346517 PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 9 / 10

18. Haidari M, Yared M, Olano JP, Alexander CB, Powell SZ. Attitudes and beliefs of pathology residents regarding the subspecialty of clinical chemistry: results of a survey. Archives of pathology & laboratory medicine. 2017; 141(2): 203–8. https://doi.org/10.5858/arpa.2015-0547-OA PMID: 27681335 19. Domı´nguez LC, Silkens MEWM, Sanabria A. The Dutch residency educational climate test: construct and concurrent validation in Spanish language. International Journal of Medical Education. 2019; 10:138–148 ISSN: 2042-6372 https://doi.org/10.5116/ijme.5d0c.bff7 PMID: 31371693 20. Amin MS, Iqbal U, Shukr I. Residency educational climate in a Pakistani postgraduate medical institute. Pakistan armed forces medical journal. 2016; 66(4): 606–12. 21. Jafri L, Siddiqui I, Khan AH, Tariq M, Effendi MU, Naseem A, et al. Fostering teaching-learning through workplace based assessment in postgraduate chemical pathology residency program using virtual learning environment. BMC medical education. 2020; 20(1): 1–2. https://doi.org/10.1186/s12909-020- 02299-8 PMID: 33097037 22. Stephen Black-Schaffer W, Robboy SJ, Gross DJ, Crawford JM, Johnson K, Austin M, et al. Evidence- Based Alignment of Pathology Residency with Practice II: Findings and Implications. Academic Pathol- ogy. 2021; 8. https://doi.org/10.1177/23742895211002816 PMID: 33889716 23. Alsalamah M, Al-Madani A. Training climate of the Saudi emergency medicine program in Riyadh. Jour- nal of health informatics in developing countries. 2020; 14(1): 1–11.

24. Bennett D, Dornan T, Bergin C, Horgan M. Postgraduate training in Ireland: expectations and experi- ence. Irish Journal of Medical Science; 2014 Jan; 183(4). https://doi.org/10.1007/s11845-013-1060-5 PMID: 24390312 25. Pacifico JL, van der Vleuten CPM, Muijtjens AMM, Sana EA, Heeneman S. Cross-validation of a learn- ing climate instrument in a non-western postgraduate clinical environment. BMC medical education. 2018; 18: 22. https://doi.org/10.1186/s12909-018-1127-0 PMID: 29370793 26. Majbar MA, Majbar Y, Benkabbou A, Amrani L, Bougtab A, Mohsine M, et al. Validation of the French translation of the Dutch residency educational climate test. BMC medical education. 2020; 20: 338. https://doi.org/10.1186/s12909-020-02249-4 PMID: 33008369 27. The Accreditation Council for Graduate Medical Education. Pathology Milestones. Available from: pathologymilestones.pdf (acgme.org). Accessed November 14, 2023. 28. Renting N, Jaarsma D, Borleffs JCC, et al. Effectiveness of supervisor training on quality of feedback to internal medicine residents: a controlled longitudinal multicenter study. BMJ Open 2023; 13:e076946. https://doi.org/10.1136/bmjopen-2023-076946 PLOS ONE Educational climate of a pathology residency program PLOS ONE | https://doi.org/10.1371/journal.pone.0303534 May 23, 2024 10 / 10