title: Residents in difficulty: a mixed methods study on the prevalence, characteristics, and sociocultural challenges from the perspective of residency program directors.
abstract: BACKGROUND
  The majority of studies on prevalence and characteristics of residents in difficulty have been conducted in English-speaking countries and the existing literature may not reflect the prevalence and characteristics of residents in difficulty in other parts of the world such as the Scandinavian countries, where healthcare systems are slightly different. The aim of this study was to examine prevalence and characteristics of residents in difficulty in one out of three postgraduate medical training regions in Denmark, and to produce both a quantifiable overview and in-depth understanding of the topic.
  
  
  METHODS
  We performed a mixed methods study. All regional residency program directors (N = 157) were invited to participate in an e-survey about residents in difficulty. Survey data were combined with database data on demographical characteristics of the background population (N = 2399) of residents, and analyzed statistically (Chi-squared test (Χ (2)) or Fisher's exact test). Secondly, we performed a qualitative interview study involving three focus group interviews with residency program directors. The analysis of the interview data employed qualitative content analysis.
  
  
  RESULTS
  73.2 % of the residency program directors completed the e-survey and 22 participated in the focus group interviews. The prevalence of residents in difficulty was 6.8 %. We found no statistically significant differences in the prevalence of residents in difficulty by gender and type of specialty. The results also showed two important themes related to the workplace culture of the resident in difficulty: 1) belated and inconsistent feedback on the resident's inadequate performance, and 2) the perceived culturally rooted priority of efficient patient care before education in the workplace. These two themes were emphasized by the program directors as the primary underlying causes of the residents' difficulty.
  
  
  CONCLUSIONS
  More work is needed in order to clarify the link between, on the one hand, observable markers of residents in difficulty and, on the other hand, immanent processes and logics of practice in a healthcare system. From our perspective, further sociological and pedagogical investigations in educational cultures across settings and specialties could inform our understanding of and knowledge about pitfalls in residents' and doctors' socialization into the healthcare system.
authors.affiliation: Centre for Health Sciences Education, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark. mkc@cesu.au.dk.
authors.forename: Mette K
authors.initials: MK
authors.lastname: Christensen
authors.affiliation: Centre for Health Sciences Education, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
authors.forename: Lotte
authors.initials: L
authors.lastname: O'Neill
authors.affiliation: Centre for Health Sciences Education, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
authors.forename: Dorthe H
authors.initials: DH
authors.lastname: Hansen
authors.affiliation: Northern Postgraduate Medical Training Region Secretariat, Skottenborg 26, 8800, Viborg, Denmark.
authors.forename: Karen
authors.initials: K
authors.lastname: Norberg
authors.affiliation: Region Hospital Randers, Skovlyvej 1, 8930, Randers Ø, Denmark.
authors.forename: Lene S
authors.initials: LS
authors.lastname: Mortensen
authors.affiliation: Centre for Health Sciences Education, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
authors.forename: Peder
authors.initials: P
authors.lastname: Charles
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D016009:Chi-Square Distribution; D002983:Clinical Competence / Q000592:standards* / Q000706:statistics & numerical data; D003718:Denmark; D004503:Education, Medical, Graduate / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D005260:Female; D017144:Focus Groups; D000068156:Formative Feedback; D006270:Health Facility Administrators / Q000523:psychology / Q000592:standards*; D006801:Humans; D007396:Internship and Residency / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D008297:Male; D036301:Qualitative Research; D066252:Sociological Factors; D013337:Students, Medical / Q000523:psychology* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires