Abstract
Background:
A supportive clinical learning environment is critical for effective surgical training, promoting professional growth and problem-solving skills. Despite global use of tools like the Postgraduate Hospital Educational Environment Measure (PHEEM), Ethiopia lacks data on the training environment for plastic and reconstructive surgery, limiting efforts toward educational quality improvement.
This study aims to explore and assess the perceptions and experiences of trainees and educators in Ethiopia’s plastic, reconstructive, and hand surgery programs regarding the training environment.
Methods:
A mixed-methods design was used at Addis Ababa University and St. Paul’s Hospital Millennium Medical College. Quantitative data were collected using the validated PHEEM questionnaire, whereas qualitative data were gathered through in-depth interviews and focus group discussions. Purposeful sampling was used, and data collection continued until thematic saturation. Thematic analysis was conducted using NVivo software.
Results:
Forty-eight residents participated (56.3% male), with a mean age of 28. The average PHEEM score was 85 of 160 (53% satisfaction). Subscale scores indicated moderate satisfaction across domains: autonomy (51.9%), teaching (55.3%), and social support (51.8%). Teaching received the highest score, whereas social support was the lowest. Qualitative analysis identified 4 key themes: poor training environment, the importance of collaboration and networking, the role of resilience, and the need to move from general to specialized plastic surgery practice.
Conclusions:
Although residents appreciated aspects of teaching, there is a clear need to strengthen social support and overall training quality. Findings highlight opportunities for targeted improvements in Ethiopia’s surgical education system.
Takeaways
Question: What is the quality of the clinical learning environment in Ethiopia’s plastic, reconstructive, and hand surgery training programs, as perceived by trainees and educators?
Findings: Using a mixed-methods approach across two major teaching hospitals, the study found moderate overall satisfaction (53%) with the training environment, with teaching rated highest and social support lowest. Qualitative analysis revealed 4 themes: poor training infrastructure, importance of collaboration, trainee resilience, and the push toward subspecialization.
Meaning: Targeted improvements in social support and structured specialization are urgently needed to enhance Ethiopia’s surgical training environment.
INTRODUCTION
Clinical learning environment is defined as the combination of social interactions, organizational culture, and physical/virtual spaces that shape learners’ experiences.1 Various tools, including the Postgraduate Hospital Education Environment Measure (PHEEM), a validated measure across specialties, are widely adopted to assess clinical educational environments.2,3
In Ethiopia, the field of plastic, reconstructive, and hand surgery (PRHS) has undergone significant development through postgraduate study programs offered at Addis Ababa University and St. Paul’s Hospital, Millennium Medical College. Since inception of formal PRHS training in Ethiopia, evolution of surgical education has been substantial. The “sandwich” training framework produced 11 surgeons trained in Ethiopia, Norway, and India between 2005 and 2009. More recently, an entirely Ethiopia-based residency program in Addis Ababa University (AAU) has graduated 42 fellows across 10 cohorts, whereas St. Paul’s Hospital Millenium Medical College (SPHMMC) added 4 graduates from three cohorts. However, assessment of the training environment remains unexplored, hindering quality assurance.4–6
This study aimed to assess the training environment for PRHS in Ethiopia. Findings will potentially contribute to improvement of teaching methods and overall effectiveness of training programs, serving as a baseline for future research in this field.
METHODOLOGY
Study Design
This study used an embedded concurrent mixed-methods design, combining quantitative (descriptive) and exploratory qualitative study.
Study Setting and Period
The study was conducted at the 2 largest teaching institutions, AAU and SPHMMC, from July to November, 2024. SPHMMC has a team of 8 plastic surgeons, 21 residents, and 32 nurses AaBET Hospital, an affiliate of SPHMMC, has a burn unit with 19 beds and a ward with 8 beds.
The AAU College of Health Sciences unit is based on ALERT (All Africa Leprosy, Tuberculosis and Rehabilitation Training Center) and Yekatit 12 Medical College. ALERT is a recognized training center for leprosy and the highest referral hospital for leprosy complications, whereas Yekatit 12 Medical College has a PRHS department with a burn unit and comprehensive cleft service.
Study Subjects
Study subjects for the quantitative part included all trainees enrolled in PRHS programs at both institutions. For the qualitative part, a purposive sampling technique was used to select consultants who were involved in educating trainees at teaching institutions. In addition, snowball sampling was used within the 2 hospitals to identify additional participants who met the inclusion criteria but were not initially reached through standard recruitment methods, enabling the inclusion of individuals with relevant experience who might otherwise have been overlooked.
Study Instrument and Procedure
PHEEM, a reliable 40-question survey, analyzes indicators of autonomy, training quality, and social support. The items were validated using qualitative research approaches.7,8
The survey was administered through a dedicated telegram group. Participants were provided with a link, and were asked to indicate their level of agreement using a 5-point Likert scale (Table 1). The overall PHEEM score was interpreted as follows: 0–40, very poor; 41–80, many problems; 81–120, more positive than negative, but with room for improvement; and 121–160, excellent.9 Furthermore, this study used a qualitative approach to gain a more comprehensive understanding. In-depth interviews and focus group discussions were conducted with consultant plastic and reconstructive surgeons and purposefully selected trainees.
Table 1.
Overview of Survey Components and PHEEM Scoring System
| Component | Details |
|---|---|
| Response scale | SA, A, U, D, SD |
| Demographic information collected | Age, gender, marital status, type of training program, duty days |
| Career and background information | Reasons for choosing plastic surgery, previous experience in plastic surgery, years worked as GP or GS |
| PHEEM scoring (standard items) | SA = 4, A = 3, U = 2, D = 1, SD = 0 |
| PHEEM scoring (negative items) | SA = 0, A = 1, U = 2, D = 3, SD = 4 |
| Negative items | Questions 4 and 6 (role autonomy), questions 1 and 2 (social support) |
A, agree; D, disagree; SA, strongly agree; SD, strongly disagree; U, uncertain.
DATA PROCESSING AND ANALYSIS
Quantitative Data
Data processing began by checking the data gathered for accuracy and completeness. Each completed questionnaire was assigned a unique code and entered into a computer using Epi Info version 3.5.1 and exported to SPSS version 26.00 for further analysis. A summary of the data was presented using frequency distributions, graphs, and plots. Continuous variables are described as mean and SD, and categorical variables as frequencies and percentages.
Qualitative Data
A total of 4 in-depth interviews and 1 focus group discussion comprising 7 participants were conducted as part of the qualitative data collection. The number of interviews (n = 4) and focus group discussions (n = 1) was determined based on thematic saturation, where additional data no longer yielded new insights. All sessions were audio-recorded with participants’ consent, transcribed verbatim, and translated from Amharic to English. Transcripts were crosschecked for accuracy and completeness, and were uploaded to NVivo-12 Plus for analysis. Inductive analysis was used to code, analyze, and interpret the data thematically.10
DATA QUALITY CONTROL
Pilot study was carried out for the survey of 8% of the study subjects using convenience sampling. Subsequently, questionnaires were distributed to participants. All the collected data were reviewed and checked for completeness.
Ethical Considerations
Clearance was obtained from the institutional research and ethics review board of SPHMMC with institutional review board number PM23/104. Participants were assured that their data would be kept confidential. For the qualitative part, participants gave written consent for the anonymous use of quotes from interviews.
RESULTS
Demographic Characteristics
The survey included 48 of 50 trainees (96% response rate), with the largest age group being 28-30 years (70.8%). Male participants accounted for 56.2% of the sample. The majority were single (64.6%), and 27.1% were married. On average, the participants supported two people in their households.
On average, there were 9.2 consultant plastic and reconstructive surgeons at the training institutions. Trainees worked with an average of 14.3 senior residents and 5.1 junior residents during internal rotations. The participants spent an average of 12.3 days physically present in the hospital per month (Table 2).
Table 2.
Demographic Characteristics Among Plastic, Reconstructive, and Hand Surgery Trainees in Ethiopia in 2023 (n = 48)
| Demographic characteristics | Total (N = 48, %) |
| Sex, n (%) | |
| Female | 21 (43.8) |
| Male | 27 (56.2) |
| Age category, y, n (%) | |
| 25–27 | 4 (8.3) |
| 28–30 | 34 (70.8) |
| 31–33 | 8 (16.7) |
| Older than 33 | 2 (4.2) |
| Marital status, n (%) | |
| Divorced | 1 (2.1) |
| Has partner | 2 (4.2) |
| Married | 13 (27.1) |
| Single, never married | 31 (64.6) |
| Widowed | 1 (2.1) |
| No. people currently supported in household, mean (SD) | 1.74 (1.76) |
| Years of experience as a practitioner before joining the training, mean (SD) | 2.43 (1.41) |
| Experience in a plastic surgery environment before joining the training, n (%) | |
| Yes | 15 (31.9) |
| No | 32 (68.1) |
| Main reason to choose to be in plastic surgery training, n (%) | |
| A plastic surgeon inspired me | 11 (23.4) |
| I have something in mind to contribute in growth of the field in our country | 17 (36.2) |
| I thought it would have a better financial compensation after I finish my training | 1 (2.1) |
| It was by accident; I don’t have a reason whatsoever | 12 (25.5) |
| Other | 6 (12.8) |
| Type of training, n (%) | |
| COSECSA training program | 5 (10.4) |
| National fellowship program | 1 (2.1) |
| National residency program | 42 (87.5) |
| Level of training, mean (SD) | 2.92 (1.56) |
| Institution, n (%) | |
| Addis Ababa university | 29 (60.64) |
| St. Paul’s hospital millennium medical college | 19 (39.6) |
| Consultant plastic and reconstructive surgeons in institution, mean (SD) | 9.23 (3.22) |
| Senior residents working while in internal rotation, mean (SD) | 14.33 (62.31) |
| Junior residents working in internal rotation, mean (SD) | 5.08 (7.01) |
| No. days of duty on average, mean (SD) | 12.33 (27.19) |
PHEEM Scale and Subscale Scores
The mean total score was 85 of 160, indicating 53% overall satisfaction of trainees. The mean scores on the subscales were as follows: perception of autonomy 29.1 of 56.0 (51.9% satisfaction); perception of teaching 33.2 of 60.0 (55.3% satisfaction); and perception of social support 22.8 of 44.0 (51.8% satisfaction). Analysis of subscale scores showed that the subscale of perception of teaching had the highest score, with a score of 55.3%. The lowest scoring subscale was perception of social support at 51.8%.(Fig. 1).
Fig. 1.
Mean percentage total score and percentage score for each subscale among plastic, reconstructive, and hand surgery trainees in Ethiopia in 2023.
Three items emerged with the highest scoring, reflecting positive perceptions among the respondents. These were no. 30, “‘There is no racial discrimination in this training’ (1.5 ± 0.9)”; no. 31, “There is no sex discrimination in this training (1.7 ± 0.9)”; and no. 32, “I have good collaboration from other doctors in my medical residency (3.9 + 0.7)” (Table 3).
Table 3.
PHEEM Items With “Satisfactory” Mean Scores (Mean > 3.5)
| No. | PHEEM Item Statement |
|---|---|
| 1 | I have an appropriate level of responsibility in this training. |
| 2 | I feel like part of a team working here. |
| 3 | I have the opportunity to practice procedures appropriate to my level. |
| 4 | I have the opportunity to actively participate in educational events. |
| 5 | There is access to educational programs relevant to my needs. |
| 6 | My clinical professors have good didactics. |
| 7 | My clinical professors are accessible. |
| 8 | The most experienced physicians provide opportunities for effective learning. |
| 9 | My clinical professors encourage me to be an independent learner. |
| 10 | I have good collaboration from other doctors in my medical residency. |
Conversely, the remaining questionnaire items were found to be less than satisfactory (mean item score < 3.5), indicating the need for further investigation and improvement. The three lowest ranked items were statement no. 24, “I have many clinical learning opportunities for my needs,” with an item score of 24 (1.5 + 1.1); statement no. 37, “There is good food service when I’m on call,” with an item score of 29 (1.6 + 0.9); and statement no. 5, “There is an informative manual for residents,” with an item score of 44 (1.9 + 1). These items should be prioritized in future program evaluation. Tables 2–4 provide more details.
Table 4.
Perception of Autonomy of Plastic, Reconstructive, and Hand Surgery Trainees in Ethiopia in 2023.
| Perception of Autonomy, n (%) | Strongly Disagree | Disagree | Not Sure | Agree | Strongly Agree | Mean ± SD |
|---|---|---|---|---|---|---|
| I have an employment contract that provides information about working hours | 14 (29.2) | 10 (20.8) | 14 (29.2) | 9 (18.8) | 1 (2.1) | 2.44 ± 1.17 |
| I had previous instructions on the program of this training | 7 (14.6) | 15 (31.2) | 9 (18.8) | 14 (29.2) | 3 (6.2) | 2.81 ± 1.20 |
| I have an appropriate level of responsibility in this training | 1 (2.1) | 5 (10.4) | 6 (12.5) | 29 (60.4) | 7 (14.6) | 3.75 ± 0.91 |
| I have to perform inappropriate tasks | 12 (25.0) | 12 (25.0) | 7 (14.6) | 11 (22.9) | 6 (12.5) | 2.73 ± 1.40 |
| There is an informative manual for residents | 20 (41.7) | 16 (33.3) | 9 (18.8) | 2 (4.2) | 1 (2.1) | 1.92 ± 0.99 |
| I am beeped/called at inappropriate times | 4 (8.3) | 9 (18.8) | 9 (18.8) | 20 (41.7) | 6 (12.5) | 3.31 ± 1.17 |
| There are precise clinical protocols in this training | 11 (22.9) | 17 (35.4) | 15 (31.2) | 5 (10.4) | 0 (0.0) | 2.29 ± 0.94 |
| My schedule complies with the National Medical Residency Commission | 5 (10.4) | 6 (12.5) | 19 (39.6) | 14 (29.2) | 4 (8.3) | 3.12 ± 1.08 |
| I have the opportunity to follow the continuation of treatment | 2 (4.2) | 7 (14.6) | 10 (20.8) | 27 (56.2) | 2 (4.2) | 3.42 ± 0.94 |
| I feel like part of a team working here | 0 (0.0) | 7 (14.6) | 3 (6.2) | 29 (60.4) | 9 (18.8) | 3.83 ± 0.91 |
| I have the opportunity to practice procedures appropriate to my level | 2 (4.2) | 7 (14.6) | 4 (8.3) | 27 (56.2) | 8 (16.7) | 3.67 ± 1.06 |
| My workload is good | 10 (20.8) | 15 (31.2) | 2 (4.2) | 21 (43.8) | 0 (0.0) | 2.71 ± 1.24 |
| This training makes me feel prepared to become an expert | 3 (6.2) | 8 (16.7) | 8 (16.7) | 24 (50.0) | 5 (10.4) | 3.42 ± 1.09 |
| My clinical professors encourage an atmosphere of mutual respect | 4 (8.3) | 4 (8.3) | 4 (8.3) | 25 (52.1) | 11 (22.9) | 3.73 ± 1.16 |
| Overall | 3.08 ± 1.23 |
The trainees’ perceptions of role autonomy, teaching, social support, and overall satisfaction were assessed. Of the total participants (N = 48), the majority had a more positive perception of their role autonomy (47.9%) and teaching quality (52.1%), with a smaller proportion perceiving their role autonomy and teaching as negative or needing improvement. A significant number of residents perceived social support as more positive than negative (52.1%), while a smaller percentage reported nonexistent or unpleasant social support. In terms of the overall score, the majority believed there was room for improvement (60.4%), although a notable percentage expressed a more positive perception (4.2%) (Fig. 1 and Tables 4–8)
Table 8.
Plastic and Reconstructive Surgery Trainees’ Perceptions of Role Autonomy, Teaching, Social Support, and Overall Score 2023 (N = 48)
| Residents’ Perceptions | Total (N = 48, %) |
|---|---|
| Perceptions of role autonomy, n (%) | |
| Very poor | 1 (2.1) |
| A negative view of one’s role | 21 (43.8) |
| A more positive perception of one’s job | 23 (47.9) |
| Excellent perception of one’s job | 3 (6.2) |
| Perceptions of teaching, n (%) | |
| very poor quality | 2 (4.2) |
| In need of some retraining | 16 (33.3) |
| Moving in the right direction | 25 (52.1) |
| Model teachers | 5 (10.4) |
| Perceptions of social support, n (%) | |
| Nonexistent | 2 (4.2) |
| Not a pleasant place | 20 (41.6) |
| More pros than cons | 25 (52.1) |
| A good supportive environment | 1 (2.1) |
| Overall score, n (%) | |
| Very poor | 2 (4.2) |
| Many problems | 15 (31.2) |
| More positive than negative but room for improvement | 29 (60.4) |
| Excellent | 2 (4.2) |
Table 5.
Perception of Teaching of Plastic, Reconstructive, and Hand Surgery Trainees in Ethiopia in 2023
| Perception of Teaching, n (%) | Strongly Disagree (0) | Disagree (1) | Not Sure (2) | Agree (3) | Strongly Agree (4) | Mean ±SD |
|---|---|---|---|---|---|---|
| My clinical professors clearly set expectations | 5 (10.4) | 6 (12.5) | 11 (22.9) | 22 (45.8) | 4 (8.3) | 3.29 ± 1.13 |
| I have a specific period to study during this training | 8 (16.7) | 16 (33.3) | 4 (8.3) | 14 (29.2) | 6 (12.5) | 2.88 ± 1.35 |
| I have good clinical supervision all the time | 6 (12.5) | 7 (14.6) | 7 (14.6) | 25 (52.1) | 3 (6.2) | 3.25 ± 1.18 |
| My clinical professors have excellent communication skills | 2 (4.2) | 12 (25.0) | 5 (10.4) | 24 (50.0) | 5 (10.4) | 3.38 ± 1.10 |
| I have the opportunity to actively participate in educational events | 2 (4.2) | 4 (8.3) | 8 (16.7) | 24 (50.0) | 10 (20.8) | 3.75 ± 1.02 |
| My clinical professors are very interested | 2 (4.2) | 7 (14.6) | 11 (22.9) | 20 (41.7) | 8 (16.7) | 3.52 ± 1.07 |
| There is access to educational programs relevant to my needs | 2 (4.2) | 7 (14.6) | 7 (14.6) | 26 (54.2) | 6 (12.5) | 3.56 ± 1.03 |
| I have feedback from my supervisors on a regular basis | 7 (14.6) | 12 (25.0) | 14 (29.2) | 14 (29.2) | 1 (2.1) | 2.79 ± 1.09 |
| My clinical professors are well organized | 4 (8.3) | 12 (25.0) | 13 (27.1) | 15 (31.2) | 4 (8.3) | 3.06 ± 1.12 |
| I have many clinical learning opportunities for my needs | 40 (83.3) | 0 (0.0) | 0 (0.0) | 8 (16.7) | 0 (0.0) | 1.50 ± 1.13 |
| My clinical professors have good didactics | 0 (0.0) | 6 (12.5) | 12 (25.0) | 28 (58.3) | 2 (4.2) | 3.54 ± 0.77 |
| My clinical professors are accessible | 0 (0.0) | 4 (8.3) | 7 (14.6) | 32 (66.7) | 5 (10.4) | 3.79 ± 0.74 |
| The most experienced physicians provide opportunities for effective learning | 1 (2.1) | 8 (16.7) | 10 (20.8) | 20 (41.7) | 9 (18.8) | 3.58 ± 1.05 |
| My clinical professors encourage me to be an independent learner | 3(6.3) | 5 (10.42) | 8 (16.67) | 28 (58.33) | 4 (8.33) | 3.52 ± 1.01 |
| My clinical professors offer me good feedback on my strengths and weaknesses | 3(6.3) | 10 (20.8) | 13 (27.1) | 19 (39.6) | 3(6.3) | 3.19 ± 1.04 |
| Overall | 3.24 ± 1.06 |
Table 6.
Perception of Social Support of Plastic, Reconstructive, and Hand Surgery Trainees in Ethiopia in 2023
| Perception of Social Support | Strongly Disagree (0) | Disagree (1) | Not Sure (2) | Agree (3) | Strongly Agree (4) | Mean ± SD |
|---|---|---|---|---|---|---|
| There is racial discrimination in this training | 31 (64.6) | 11 (22.9) | 4 (8.3) | 1 (2.1) | 1 (2.1) | 1.54 ± 0.90 |
| There is sex discrimination in this training | 26 (54.2) | 14 (29.2) | 6 (12.5) | 2 (4.2) | 0 (0.0) | 1.67 ± 0.86 |
| I have good collaboration from other doctors in my medical residency | 0 (0.0) | 3 (6.2) | 4 (8.3) | 34 (70.8) | 7 (14.6) | 3.94 ± 0.70 |
| I have adequate access to career guidance | 5 (10.4) | 15 (31.2) | 11 (22.9) | 15 (31.2) | 2 (4.2) | 2.88 ± 1.10 |
| This hospital has good quality accommodation for residents, especially when they are on call | 22 (45.8) | 14 (29.2) | 6 (12.5) | 5 (10.4) | 1 (2.1) | 1.94 ± 1.10 |
| I feel physically safe in the hospital environment | 4 (8.3) | 10 (20.8) | 14 (29.2) | 19 (39.6) | 1 (2.1) | 3.06 ± 1.02 |
| There is a culture of not blaming in this training | 4 (8.3) | 9 (18.8) | 18 (37.5) | 17 (35.4) | 0 (0.0) | 3.00 ± 0.95 |
| There is good food service when I’m on call | 30 (62.5) | 10 (20.8) | 5 (10.4) | 3 (6.2) | 0 (0.0) | 1.60 ± 0.92 |
| My clinical professors are good counselors | 1 (2.1) | 8 (16.7) | 12 (25.0) | 22 (45.8) | 5 (10.4) | 3.46 ± 0.97 |
| I feel very satisfied with my current job | 6 (12.5) | 12 (25.0) | 17 (35.4) | 12 (25.0) | 1 (2.1) | 2.79 ± 1.03 |
| There are good counseling opportunities for residents who fail so they can satisfactorily complete their training | 7 (14.6) | 16 (33.3) | 19 (39.6) | 5 (10.4) | 1 (2.1) | 2.52 ± 0.95 |
| Overall | 2.58 ± 0.95 |
Table 7.
Overall Score of PHEEM
| Overall Score of PHEEM | |
|---|---|
| 0–40 | Very poor |
| 41–80 | Many problems |
| 81–120 | More positive than negative but room for improvement |
| 121–160 | Excellent |
| Subscale 1: perception of role autonomy | |
| 0–14 | Very poor |
| 15–28 | A negative view of one’s role |
| 29–42 | A more positive perception of one’s job |
| 43–56 | Excellent perception of one’s job |
| Subscale 2: perception of role teaching | |
| 0-15 | Very poor quality |
| 16-30 | In need of some retraining |
| 31-45 | Moving in the right direction |
| 46-60 | Model teachers |
| Subscale 3: perception of role social support | |
| 0–11 | Very poor quality |
| 12–22 | In need of some retraining |
| 23–33 | Moving in the right direction |
| 34–44 | Model teachers |
Sex-based Differences in PHEEM Scores and Overall Satisfaction with Training
An analysis of male and female postgraduate trainees shows no meaningful gender differences in the overall educational environment, based on the total PHEEM score and its 3 subscales: perception of role autonomy, teaching, and social support. Both groups report nearly identical mean total PHEEM scores (approximately 85.5–85.8) and similar subscale averages, with comparable SDs. All P values are well above conventional significance thresholds (0.05), indicating no statistically significant differences between genders. These findings suggest that male and female trainees perceive their educational environment, including autonomy, teaching, and social support, in much the same way (Table 9).
Table 9.
Sex-based Differences in PHEEM Scores and Overall Satisfaction with Training
| Characteristic | Mean, Men (n = 70) | SD | Mean, Women (n = 70) | SD | P |
|---|---|---|---|---|---|
| Total PHEEM | 85.8 | 20.3 | 85.5 | 22.2 | 0.962 |
| Perception of role autonomy | 29.5 | 6.4 | 28.5 | 9.2 | 0.686 |
| Perception of teaching | 33.0 | 11.5 | 34.3 | 10.9 | 0.692 |
| Perception of social support | 23.3 | 5.6 | 22.6 | 5.8 | 0.699 |
Qualitative Insight
A total of 7 key informant interviews (KIIs) were conducted with plastic and reconstructive surgeons from the 3 major teaching institutions in Addis Ababa. These included 2 participants from SPHMMC, 3 from ALERT Hospital, and 2 from Yekatit 12 Medical College. All interviewees were male faculty members actively involved in residency training. The KIIs were selected purposively to capture insights from experienced educators across diverse institutional settings. Four themes emerged from the analysis.
Theme 1: Poor Training Environment
Participants described systemic shortcomings in the early training environment, including unstructured trainee selection, lack of autonomy for faculty in decision-making, pressure to accept excessive trainee numbers, and a limited variety of clinical cases.
Illustrative Quotes
“The training environment was inadequate and poorly structured”—KII 1, ALERT.
“Trainee selection excluded capable GPs due to a single exam”—KII 2, Yekatit 12.
“We had to accept 350 students annually regardless of capacity”—KII 1, ALERT.
“Flap failures showed our problem was the environment, not just skill”—KII 3, SPHMMC.
“Living conditions and basic facilities for trainees were unacceptable”—KII 5, Yekatit 12.
Theme 2: Importance of Collaboration and Networking
Collaboration was highlighted as a key strength of the training program. From the program’s initiation through international partnerships to peer learning during complex procedures, a spirit of teamwork supported skills acquisition and motivation.
Illustrative Quotes
“It was a foreign partner who initiated the program”—KII 2, Yekatit 12.
“We took turns during surgeries to learn both roles”—KII 7, ALERT.
“Networking is essential—success inspires others”—KII 4, ALERT.
“I gave up a scholarship for a younger colleague who had greater potential”—KII 1, ALERT.
Theme 3: Resilience in the Face of Challenges
Despite limited resources, the training program has persisted through creative problem-solving and unwavering determination. Participants described overcoming equipment shortages, fear of complex procedures like brachial plexus surgeries, and lack of expert supervision, which gradually led to local innovation and improved outcomes.
Illustrative Quotes
“We used a tiny knife for grafting large wounds—teamwork made it work”—KII 5, Yekatit 12.
“We were the first to manage brachial plexus injuries locally”—KII 7, ALERT.
Theme 4: Need for a Shift from General to Subspecialty Practice
There was consensus that the future of plastic surgery training in Ethiopia lies in developing subspecialties. Participants advocated for structured training tracks in microsurgery, breast reconstruction, and aesthetic surgery, emphasizing their relevance to local needs and global standards.
Illustrative Quotes
“We must move from generalist to specialist training”—KII 1, ALERT.
“Understanding why patients reject reconstruction requires local research”—KII 2, Yekatit 12.
“Aesthetic surgery improves patients’psychological well-being—it’s not a luxury”—KII 3, SPHMMC.
DISCUSSION
Educational environment significantly affects teaching and learning. The PHEEM is an effective tool for assessing the strengths and weaknesses of plastic and reconstructive training programs. This study indicates areas for improvement, suggesting the need for program directors to enhance progress.
The high response rates (96% for the quantitative part) observed in this study indicate trainees’ willingness to seize the opportunity to express their opinions. Gender representation showed that 56.2% of the participants were male and 43.8% were female. Notably, in other surgical subspecialties, the percentage of women among surgical trainees was relatively low, at 22% in the United States and 28% in the Netherlands.11 However, our findings are consistent with the observation that women were more prominently represented in the field of plastic surgery, indicating the highest proportion compared with other subspecialties. This parallelism further strengthens our results, and supports the notion of increased female representation in plastic surgery.12
The participants spent an average of 12.3 days on duty per month, underscoring the demanding nature of their training. This intensity parallels findings in plastic surgery and surgical specialties more broadly, where heavy workloads and frequent on-call demands have been strongly associated with elevated burnout rates, (eg, 32%–37% emotional exhaustion, 35%–42% depersonalization, and low personal accomplishment).13 Other surveys confirm similar concerns, with burnout being prevalent across trainees and surgeons globally.14,15
Given this context, there is a growing impetus for graduating trainees to pursue subspecialties offering a better work–life equilibrium, and a pressing need to embed wellness strategies within training programs. A systematic review of wellness in plastic surgery training highlights a notable scarcity of high-quality research and a lack of organizational interventions to promote trainee well-being.16,17 Broader literature emphasizes that preventing burnout requires a multi-pronged approach, addressing not only individual resilience but also modifying workplace systems to reduce workload strain, enhance autonomy, and foster support networks.18–20
Neglecting such interventions risks exacerbating stress and burnout, which are consistently linked to strained relationships, reduced productivity, decreased job satisfaction, elevated risk of errors, and impaired mental health.13 Therefore, it is crucial to explore and implement evidence-based strategies, such as workload regulation, wellness programming, and structural support, to safeguard trainee well-being and sustain performance in demanding training environments, as not paying due attention to these factors may cause increased stress and burnout, strained relationships, reduced productivity and performance, decreased job satisfaction, increased risk of mistakes and accidents, and a negative impact on overall well-being.21–23
Based on the published guide for interpreting mean scores, the findings of this study suggest a postgraduate environment that is generally positive but still has room for improvement. A global mean score of 85 indicates satisfaction in 53% of trainees and a more positive perception among them. When comparing the mean PHEEM score of this study with that of economically stronger countries, the findings appear relatively lower. This may reflect systemic constraints such as high clinical workload, limited faculty-to-resident ratios, and weaker institutional support systems. In contrast, high-income countries benefit from structured mentorship, faculty development, and stronger social support, which contribute to their higher PHEEM scores. Studies in Saudi Arabia, Japan, and Italy reported higher mean scores of 100, 102.4, and 106.8, respectively.3,24,25 Nevertheless, it is important to note that a study conducted by Fasika Amdesillase and his colleagues in 2014 at Mekelle University reported a slightly higher mean score of 93.26 Comparable results from Pakistan (79.8–85.2) suggest that Ethiopia’s challenges are shared across low- and middle-income countries, where resource limitations and underdeveloped residency support structures impact training environments.3 Certain practices from countries with higher scores, such as structured mentorship and resident wellness programs, may be adapted to Ethiopia. However, resource-sensitive approaches, like peer mentorship, structured orientation manuals, and regular formative feedback, are likely to be more feasible and sustainable locally.
The highest mean score from the subscales in our study was for perception of teaching, 33.18, indicating 55.3% satisfaction, and the lowest was for perception of social support, 22.8, showing 51.8% satisfaction. A similar pattern was reported in Pakistan in 2018, Saudi Arabia in 2018, and Japan in 2006.24,25,27 Therefore, despite scoring relatively high, there is room for improvement, focusing on improving the perception of teaching, strengthening social support systems, and learning from successful practices in other countries.
In addition, future program evaluations should prioritize addressing the areas identified as having the lowest rankings. These include statement no. 24, which pertains to the availability of clinical learning opportunities tailored to residents’ needs, as indicated by an item score of 24 (1.5 + 1.13). Additionally, statement 37 highlights the need for improvement in the food service provided during on-call shifts, as it received an item score of 29 (1.6 + 0.92). Finally, statement 5 emphasizes the importance of developing an informative manual specifically designed for residents, with an item score of 44 (1.92 + 0.99). Not giving due emphasis to preparing a guiding manual for residents can cause inconsistent training, increased dependency on instructors, time-consuming inquiries, reduced confidence, potential for errors, etc.20,28
Qualitative analysis revealed significant concerns regarding the poor training environment experienced by educator surgeons; however, participants also emphasized key strengths such as strong peer collaboration, mentorship, and resilience, and identified opportunities for growth through subspecialty development and improved institutional support. Issues such as limitations in the selection process, focus on quantity over quality, lack of case variety, and substandard quality of life for trainees were identified as areas that require attention and improvement.
In addition, the theme of resilience showcased the determination and adaptability of training programs in Ethiopia. Despite limited resources, participants demonstrated the ability to learn from challenges, improvise, and develop innovative solutions. Finally, the theme of a shift from general to specialty-based plastic surgery practice underscored the recommendations of the participants. They emphasized the importance of concentrating on subspecialties such as microsurgery, breast surgery, and aesthetic surgery.
Strengths and Limitations
This mixed-methods study offers a valuable and in-depth assessment of Ethiopia’s PRHS training environment, using both validated quantitative tools and thematic qualitative analysis involving educator surgeons. It is one of the first studies to explore this topic in Ethiopia and provides baseline data for future research.
However, the quantitative component was descriptive and cross-sectional, limiting causal inferences. In the qualitative part, subjective interpretation and limited diversity of perspectives remain potential limitations. Despite these constraints, the study’s practical relevance and rich insights highlight key areas for improving surgical education.
Recommendation
This study highlights important opportunities to improve plastic surgery training in Ethiopia. Building on the positive perception of teaching, investment in innovative teaching methods and faculty development is recommended to enhance trainee engagement and satisfaction. Strengthening social support through structured mentorship and peer support networks can foster well-being and collaboration. Encouraging local and international partnerships through conferences, workshops, and research can broaden trainees’ skills and perspectives.
CONCLUSIONS
In conclusion, the study revealed an overall PHEEM score of 85 (53% satisfaction), indicating a generally positive perception of the educational environment, with room for improvement in autonomy, teaching, and social support. The highest score was observed for the perception of teaching, and the lowest score was found for the perception of social support. In-depth interviews and focused group discussions further highlighted four major themes: the need to address the poor training environment through the efforts of responsible bodies, the importance of collaboration and networking, the role resilience demonstrated despite challenges, and the necessity for a shift towards a specialty-based approach in plastic surgery practice.
DISCLOSURES
The authors have no financial interest to declare in relation to the content of this article. COSECSA Global Surgery Research Program, funded by the Intuitive Foundation.
ACKNOWLEDGEMENT
The authors thank the Intuitive Foundation and SPHMMC Research office for their generous financial support, which made this research possible.
Footnotes
Published online 26 May 2026.
Disclosure statements are at the end of this article, following the correspondence information.
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