PROFESSIONAL EXPERIENCES, TRAINING ATTITUDES AND EXPECTATIONS OF RESIDENTS IN DENTISTRY: A NATIONWIDE SURVEY

Abstract

Background

Worldwide, it has been acknowledged that feedback from students and trainees is important for evaluation of training. However, there is limited data on the professional experiences, expectations and attitude of residents in dentistry to their training.

Aim

This study aimed to analyse the professional experiences, expectations, and attitudes of dentistry residents to training in Nigeria.

Design of the study

Cross-sectional study.

Setting

All the accredited Nigerian Teaching Hospitals with dental surgeons undergoing residency training in any of the 10 specialties examined in West Africa.

Methodology

The study was conducted through a self- administered closed anonymous 46-items questionnaire adapted from that used for general surgery residents in the United States of America. The collected data included various aspects of the technical, human and professional domains of the expectations, attitudes and perceptions of dental residents to their training. Data from the questionnaires were collated and entered into Microsoft Excel version 10, 2002 (Microsoft, Redmond, WA, USA) and processed using STATA software (StataCorp LLC, Texas, USA). Categorical variables were calculated as proportions and percentages with 95% corresponding intervals. χ2 - test was used to analyse the association between selected demographic characteristics and some of the responses. Fischer’s exact test was done where necessary. Statistical significance was set at p≤0.05 and tests were two- sided.

Results

Nigeria has 11 accredited training institutions for residency in dentistry, of which 214 residents participated representing 93% of the estimated total. Most were males (133, 65.2%) with male to female ratio of 1.9:1. Residents aged between 30-34 years of age made up 41.5% while 77.4% were married. Close to one third (31.8%) were residents in oral and maxillofacial surgery. Residents expressed low level of satisfaction with the quality of residency training (64, 30.3%; 95% CI 24.5-36.9) and believe that they had appropriate level of operating skill from their training (96, 45.3%; 95% CI 38.6-52.1). Few agreed that the training programme had adequate support structures for struggling residents (64, 30.3%; 95% CI 24.5-36.9) but many (105, 65.2%; 95% CI 57.5-72.2) felt the residency programme took too long. More males (31.8%) than females (14.9%) expressed satisfaction with the level of didactic teaching during the residency programme with statistically significant difference (p=0.032). Orthodontic residents expressed the greatest approval (54.5%) for the support structures put by the training programme for struggling residents, while the least were in oral medicine (12.5%) with high statistically significant difference (p=0.014). The level of support from faculty/departmental member to struggling resident was felt to be most adequate by those who had passed the primaries exam (69.5%) with statistically significant difference from other residents (p= 0.021).

Conclusion

Overall, this study showed that Nigerian dentistry residents had low level of satisfaction with the quality of their training indicating the need for a holistic review of the training curriculum and conduct of trainers. There is need to reinforce motivating and tackle demotivating factors identified in this study to improve the response of dentistry residents to their training as these would improve the value of competency assessments undertaken by the postgraduate colleges while sustaining interest in the profession for the interest of the wider society.

Introduction

Several studies have substantiated that most dental undergraduates intend to specialise later in their careers 1, 2. Specialist training is commonly acquired through the residency programme. However, the residency programme is not all together rosy. In an earlier study, Yeo et al3 , characterised lifestyle issues associated with residency among general surgeons. They found that while most were satisfied with residency programme, 20.5% felt the training duration was too long (5years) while 15.3% had considered leaving the programme within the past year3. A previous Nigerian study mentioned ‘perceived phobia’ for the residency programme by students and doctors alike with most resident doctors complaining that consultants contributed less than 50% to their training. Other challenges included poor state of training facilities and low remuneration package4 However, the Nigerian report did not specify the specialties of the study subjects, also the evaluation of other human, professional and technical dimensions of residency training were not done. A later study focused exclusively on Nigerian general surgery residents 5 but we did not find a similar report on dental surgery residents in the literature.

In English-speaking West Africa, residency training programmes for dental surgeons and other medical specialists have been conducted in accredited university teaching/specialist hospitals for more than 30years6. The steps and general modalities of training have been previously reported5.

According to Kirkpatrick7, evaluation of training could be done at 4 increasing levels: level one (reaction), level two (learning), level three (behaviour) and level four (results). Level one (reaction) measures how the students feel and their personal responses to training 8. This is essential for quality assurance and further improvement of the training programme7. It could also indicate whether learning is possible and provide baseline data for higher levels of evaluation such as the competency tests conducted at examinations7,8.

Level One evaluation (reaction) is most commonly assessed using students’ experiences, attitudes and perceptions of the training programme7,9. While the postgraduate medical colleges conduct competency tests through examinations and publish results of the same, to our knowledge, there has been no published report of the expectations, attitudes and perceptions of dental surgery residents in particular to their training in Nigeria. The purpose of this Professional Experiences, Training Attitudes of Residents in Dentistry (PETARD) study was to analyse the professional experiences, expectations, perceptions and attitudes of dental residents to training in Nigeria. The specific objectives were (1) to determine the demographics of dental residents; (2) to assess their experiences, expectations, and attitudes towards residency training and (3) to evaluate the relationship between some socio-demographic characteristics to selected features of (2). Finally, the study was to recommend measures to improve dental residency training in Nigeria.

SUBJECTS AND METHODS

Study Design and Sample

This cross-sectional Professional Experiences, Training Attitudes and Expectations in Dentistry (PETARD) study was conducted among dental residents at the accredited Nigerian teaching hospitals between September and December 2017. The sample comprised all dental surgeons undergoing residency training in any of the 10 specialties examined in West Africa. Questionnaires were distributed through a dental surgery resident (site coordinator) at the training institutions to encourage freedom of expression. Each site coordinator was briefed about the study especially about the study tool. The coordinator distributed the survey material and retrieved both blank and filled questionnaires at the end of the survey. These were sent back to the principal investigator. The questionnaire had an explanatory note on the rationale for the study and the confidentiality of the responses. Acceptance and completion of the questionnaire was taken as implied consent. The research protocol was approved by the Ministry of Defence Health Research Ethical Committee.

Survey Instrument

The survey was conducted through a self- administered closed anonymous questionnaire adapted from Yeo et al3 for United States of America general survey residents. The questionnaire inquired about the technical, human and professional domains of the expectations, attitudes and perceptions of residents according to Herbella et al10. The adapted questionnaire had two parts. The first part had 10 questions on demographics while the 2^nd part had 46 questions. The 2^nd part was subjected to further discussions among dental surgery residents and their trainers (consultants) in 3 Nigerian teaching hospitals before it was finalised. The Cronbach’s alpha for the 46-items was 0.751 which indicated they had good internal consistency (reliability). The final 46-items questionnaire was tested on 70 residents, the data generated was subjected to principal factor analysis with a Varimax orthogonal rotation. An examination of the Kaiser-Meyer-Olkin measure of sampling adequacy showed that the sample was factorable (KMO=0.956). The first part of the questionnaire had 10 questions for demographic data such as training centre, age group, sex, marital status, specialty, number of years in residency training, last exam passed, sponsorship and main reason for choosing dental surgery residency training. The 2^nd part with 46 questions sought information on professional experiences, ethical issues, motivating factors, attitudes and opinion on the future of their dental specialty. The questions were structured as statements while the respondent indicated level of agreement using a 5-point Likert response scale, ranging from strongly agree to strongly disagree.

Data Analysis

Data from the questionnaires were collated and entered into STATA software (Version 13; StataCorp; College Station, TX, USA). The strongly agree/agree and disagree/strongly disagree responses were merged during data analysis. Categorical variables were calculated as proportions and percentages with 95% corresponding intervals. χ2- test was used to analyse the association between selected demographic characteristics and some of the responses. Fischer’s exact test was done where necessary. Statistical significance was set at p≤0.05 and tests were two- sided.

Results

There are about 230 dental surgery residents in 11 accredited training institutions in Nigeria, of which 214 participated in the PETARD survey, representing 93%. The residents who did not participate were reportedly not available during the period of the study, but no available resident declined participation. The Council of American Survey Research Organisations defines a complete survey as that with ˃80% items completed. Our survey had 93.7 % of items completed.

Table 1a summarises the demographic characteristics of the respondents. Most respondents were males (133, 65.2%), male to female ratio 1.9:1; aged between 30-34 years of age (41.5%) and married (164, 77.4%). Table 1b represents the specialisation, duration and sponsorship characteristics. Close to one third (31.8%) were residents in oral and maxillofacial surgery while the least were in general dental practice/family dentistry (3.7%). There were more junior residents, yet to pass part One (46, 55%) and less than a third were ≤ 1 year in the residency programme (67, 31.6%). Most residents were university/teaching hospital staff (158, 76%), and a few were on self- sponsorship (16, 7.7%). Figure 1 showed the need for knowledge (145, 67.8%), followed by prospect for better pay (7.9%) and as only available option (4.7%) were main motivations for the pursuit of residency training.

Table 1a. Demographic characteristics of the dentistry residents.

Characteristic	No. (%) of Respondentsa
Age in years:	(n=214)
25-29	20 (9.4)
30-34	88 (41.5)
35-40	74 (34. 9)
> 40	30 (14.2)
Sex:
Males	133 (65.2)
Females	71 (34.8)
Marital status:
Single, no relationship	21 (9.9)
Single, in a relationship	24 (11.3)
Married	164 (77.4)
Divorced	1 (0.5)
Widowed	2 (0.9)
a Column may not add up to 214 due to missing values

Table 1b. Specialisation, duration and sponsorship details of dentistry residents.

Characteristics	No. (%) of Respondentsa(n=214)
Specialty:
Oral and maxillofacial surgery	68 (31.8)
Conservative Dentistry	30 (14.0)
Paedodontics	16 (7.5)
Orthodontics	34 (15.9)
General Dental Practice	8 (3.7)
Dental Public Health	12 (5.6)
Prosthodontics	9 (4.2)
Oral Medicine	16 (7.5)
Oral Pathology	11 (5.1)
Periodontics	10 (4.7)
No of years spent in residency programme:
≤ 1	67 (31.6)
2	24 (11.3)
3	14 (6.6)
4	29 (13.7)
5	24 (11.3)
6	20 (9.4)
>6	34 (16.0)
Exam passed:
Yet to pass any exam	19 (9.0)
Primaries	97 (46.0)
Part One	94 (44.5)
Part 2	1 (0.5)
Sponsorship:
University/Teaching hospital staff	158 (76.0)
Supernumerary	34 (16.3)
Self	16 (7.7)
aColumn may not add up to 214 due to missing values.

Fig 1. Main reason for dentistry residency.

There were questions on the technical, human and professional domains of the expectations, attitudes and perceptions in this study. Residents expressed low level of satisfaction with the quality of residency training (64, 30.3%; 95% CI 24.5-36.9) and believed that they had appropriate level of operating skill from their training (96, 45.3%; 95% CI 38.6-52.1). Few agreed that the training programme had adequate support structures for struggling residents (64, 30.3%; 95% CI 24.5-36.9) but 134 (63.8%; 95% CI 57.0-70.1) had adequate support from departmental/faculty members while struggling in the programme. Most residents (105, 65.2%; 95% CI 57.5-72.2) felt the residency programme took too long to complete while some (72, 34.3%; 95% CI 28.1-41.0) agreed that the personal cost of training was not worthwhile in their perspective. Also, few (18, 8.6%; 95% CI 5.5-13.4) were worried that their dental specialty was going to become obsolete but most agreed (140, 66.0%; 95% CI 59.3-72.1) that post-residency specialist training was necessary. Specialist training for a dentist was considered a necessity for success by most respondents (142, 67%; 95% CI 60.3-73) and that the training improved their prospects for better income (160, 74.8%; 95% CI 68.5-80.2). Regarding performance of tasks, some residents (43, 20.2%; 95% CI 15.3-26.2) felt the consultant/seniors would be disappointed if they needed help with a procedure but more (99, 47.1%; 95% CI 40.4-53.9) worried about performing poorly in the presence of senior residents. Thirty- seven residents (14.6%; 95% CI 10.4-20.1) were worried that they would not have enough confidence to operate independently after training. Concerning stress and concern of residents, 133 (63%; 95% CI 56.3-69.3) were eager to come to work daily but more than a quarter (62, 29.2%; 95% CI 23.5-35.8) had considered leaving the training programme in the last one year. Work stress causes a strain in the families of 87 respondents (41.2%; 95% CI 34.7-48.1) and most (204, 95.8%; 95% CI 92.0-97.8) really cared for their patients while there was worry about hurting patients among 120 dental surgeons (56.9%; 95% CI 50.0-63.4). Table 2 summarised the professional expectations, experiences and attitudes of dental residents to many aspects of their training in Nigeria.

Table 2. SUMMARY OF EXPERIENCES, EXPECTATIONS AND ATTITUDES OF DENTISTRY RESIDENTS.

Question	No. (%) of respondentsa
	Agree	Neutral	Disagree
1.Overall, I am very satisfied with the quality of my training program	64, 30.3	45, 21.3	102, 48.3
2.As a dental resident, my opinions are important.	123, 58.6	55, 26.2	32, 15.2
3.My training program has support structures in place that provide me with someone to turn to when am struggling.	64, 30.3	43, 20.4	104, 49.3
4.To be a good dental specialist, it seems am expected to be less sensitive.	45, 21.3	31, 14.7	135, 64
5.I feel I can turn to a member of the department/faculty when I have difficulties in the program.	134, 63.8	37, 17.6	39, 18.6
6.I feel I can turn to member of the department/faculty when am struggling with how to treat a patient.	195, 91.5	13, 6.1	5, 2.4
7.I look forward to coming to work every day.	133, 63.0	48, 22.8	30, 14.2
8.I am satisfied with the didactic teaching in my program.	53, 25.4	61, 29.2	95, 45.4
9.I am satisfied with the operative experience in my program.	67, 31.9	49, 23.3	94, 44.8
10.I have considered leaving my program in the last year.	62, 29.2	43, 20.3	107, 50.5
11.I do not feel respected by my consultant.	48, 22.7	54, 25.6	109, 51.7
12.I am happy when am at work.	118, 55.1	75, 35.1	21, 9.8
13.Residency training is too long.	105, 65.2	30, 18.6	26, 16.2
14.I often feel that my challenges are more than I can manage.	46, 21.7	60, 28.3	106, 50.0
15.I am uncomfortable with some of the ethical decision I see the consultant make.	54, 25.2	77,36.0	83, 38.8
16.I am giving so much to do that I am afraid I will hurt someone.	30, 14.3	38, 18.2	141, 67.5
17.I feel that my operating skill level is appropriate.	96, 45.3	49, 23.1	67, 31.6
18.I worry that I will not have enough confidence to perform procedures independently by the time I finish training.	31, 14.6	19, 9.0	162, 76.4
19.I am not happy with the personality that I must have to become a consultant	36, 16.9	44, 20.7	133, 62.4
20.The duration of my working hours cause a strain on my family life.	83, 39.3	42, 19.9	86, 40.8
21.The stress of my work is causing a strain on my family.	87, 41.2	41, 19.4	83, 39.3
22. My consultant/senior will think worse of me if I ask of help when I do not know how to do a procedure.	43, 20.2	39, 18.3	131,61.5
23.My consultant/senior will think worse of me if I ask for help when I do not know how to manage a patient.	51, 24.1	31, 14.6	130, 61.3
24.I really care about my patient.	204, 95.8	3, 1.4	6, 2.8
25.I worry about performing poorly in front of my senior residents.	99, 47.1	43, 20.5	68, 32.4
26.I worry about performing badly in front of my consultant.	136, 64.4	27, 12.8	48, 22.8
27.The personal cost of residency training is not worth it to me.	72, 34.3	53, 25.2	85, 40.5
28.I get along well with my fellow residents	189, 89.1	15, 7.1	8, 3.8
29.I get tremendous amount of satisfaction working with patients.	127, 67.9	46, 24.6	14, 7.5
30.I feel well fitted for my training program	146, 69.2	49, 23.2	16, 7.6
31.I am committed to complete my residency program	180, 85.7	24, 11.4	6, 2.9
32.I enjoy my work	167, 80.7	29, 14.0	11, 5.3
33.I worry about hurting patient	120, 56.9	34, 16.1	57, 27.0
34.My working experience so far has helped me to develop my skills well.	183, 85.9	16, 7.5	14, 6.6
35.If I have a problem I feel I can count on other residents to help me out.	183, 85.9	21, 9.9	9, 4.2
36. I worry that my specialty is going to become obsolete.	18, 8.6	17, 8.2	173, 83.2
37.I worry that other professionals will take over some of procedures that I do.	45, 21.1	37, 17.4	131, 61.5
38.The dentist in my field must become specialty trained in order to be successful.	142, 67.0	36, 17.0	34, 16.0
39.I will need to complete additional specialty training after I complete my residency training in order to be competitive in the job market.	140, 66.0	29, 13.7	43, 20.3
40.If I complete specialty training, I will have a better income.	160, 74.8	41, 19.1	13, 6.1
41.If I complete specialty training, I will have a better lifestyle.	136, 63.8	59, 27.7	18, 8.4
42.Consultants in dental specialties do not make as much money now as they use to.	51, 23.9	74, 34.7	88, 41.3
43.I worry about the high cost of malpractice insurance.	73, 34.8	104, 49.5	33, 15.7
44.One of the factors that influenced my decision to become a dental specialist was the expectation of good financial compensation.	119, 55.6	41, 19.2	54, 25.2
45.Each year my expectations for the amount of money I am going to make when I finish training seem to go down.	81, 38.0	71, 33.3	61, 28.6
46.I worry about making enough money as a consultant.	70, 32.7	66, 30.8	78, 36.5
aTotals may not add to indicated sum due to missing values.

Table 3a-Table 3d respectively analysed selected items for association with sex, age groups, dental specialty, exam passed and whether residency training took too long to complete. In Table 3a, male dental residents had more confidence in the support structures of the training programme than females (32.8% vs 28.6%) but the difference was not statistically significant (p=0.747). Other selected items analysed by sex had more males than female in agreement but the differences were not statistically significant except that more males (31.8%) than females (14.9%) expressed satisfaction with the level of didactic teaching during the residency programme with statistically significant difference (p=0.032). The dental residents surveyed were placed into 4 age groups and their analyses was presented in Table 3b under categories of 25-29 years, 30-34years, 35-40years and above 40years of age. The level of support to struggling dental residents by department/faculty members was felt to be most adequate by those above 40years of age (73.3%) but difference in perception between various age groups was not statistically significant (p=0.652). The need to complete additional specialty training after residency to be competitive in the job market was expressed mostly by those between 35-40years of age (77%) and least by those 25-29years old (47.4%) but the difference was statistically significant (p=0.029). Among the 10 dental specialties where dental surgeons undertake residency training in Nigeria, 5 with the higher number of residents were selected (oral and maxillofacial surgery, conservative dentistry, paedodontics, orthodontics and oral medicine) for analysis based on the selected questions used for other demographic characteristics. Table 3c showed the analysis of selected items for residents of these 5 dental specialties. Orthodontic residents expressed the greatest approval (54.5%) for the support structures put by the training programme for struggling residents, while the least were in oral medicine (12.5%) with high statistically significant difference using Fischer’s exact test (p=0.014). Orthodontic residents similarly expressed the greatest approval for all the other selected items in Table 3c. The level of satisfaction with operative experience was greatest among orthodontic residents (52.9%) and least for oral medicine residents (12.5%) with high statistically significant difference (p=0.001). Satisfaction with didactic teaching was also greatest among residents in orthodontics (36.4%) than others with statistical significance (p=0.022). Table 3d of the analysis on the basis of last exam passed (nil, primaries and part One) showed mixed responses to the selected items. The level of support from faculty/departmental member to struggling resident was felt to be most adequate by those who had passed the primaries exam (69.5%) followed by Part One (64.1%) and nil exam (31.6%). The differences were statistically significant (p= 0.021). The need to complete additional specialty training after residency to be competitive in the job market was expressed mostly by those who had passed the Part One exam (76.3%) and least by those who passed primaries exam (55.2%). The difference in this perception was statistically significant (p=0.022). The perception that residency programme took too long was most among Part One exam residents (69.6%) followed by primaries (63.1%) and nil exam (61.5%) but this difference was not statistically significant (p=0.055).

Table 3a. Analysis of Strongly agree/agree Responses to Selected Items by Sex.

Item	No (%)of allRespondents(N=214)a	Sex Distribution		P Valueb
		Male(N=133)	Female(N=71)
a. Training programme has adequate support structures	63(31.3)	43(32.8)	20(28.6)	0.747
b. Support from department/faculty member	127(63.5)	88(66.7)	39(57.3)	0.407
c. Need for training after completion of residency	131(64.9)	89(66.9)	42(60.9)	0.133
d. Satisfaction with operative experience	66(33)	51(38.3)	12(22.4)	0.074
e. Satisfaction with didactic teaching	52(26.1)	42(31.8)	10(14.9)	0.031
f. Residency training too long	101(66.5)	61(67.8)	40(64.5)	0.915
aTotals may not add to indicated sum due to missing values.
bComparison of males vs females, calculated by χ2- test statistical significance at P ≤ 0.05

Table 3d. Analysis of Strongly agree/Agree Responses to selected Items by Exam Passed.

Item	No (%)of allRespondents(N=208)a	Last Exam Passed			P Value
		Nil (N=19)	Primaries (N=95)	Part I (N=93)
a. Training programme has adequate support structures	62(29.8)	4(21.0)	31(32.6)	27(29)	0.689
b. Support from department/faculty member	13(63.6)	6(31.6)	66(69.5)	59(64.1)	0.021
c. Need for training after completion of residency	137(65.9)	13(68.4)	53(55.2)	71(76.3)	0.022
d. Satisfaction with operative experience	66(31.9)	5(26.3)	31(33.3)	299(30.8)	0.564
e. Satisfaction with didactic teaching	50(24.4)	5(26.3)	22(23.6)	23(24.7)	0.552
f. Residency training too long	104(65.8)	8(61.5)	48(63.1)	48(69.6)	0.055
aTotals may not add to indicated sum due to missing values.
bComparison of Last Exam Passed vs selected items, calculated by χ2- test.

Table 3b. Analysis of Strongly agree/Agree Responses to Selected Items by Age Groups.

Item	No (%)of all Respondents(N=212)a	Age Groups(Years)				P Valueb
		25 – 29 (N=20)	30 – 34 (N=88)	35 – 40 (N=74)	≥ 40(N=30)
a. Training programme has adequate support structures	62(29.7)	7(35)	25(28.7)	20(27.8)	10(33.3)	0.619
b. Support from department/faculty member	132(63.4)	13(65)	51(60)	46(63)	22(73.3)	0.652
c. Need for training after completion of residency	137(65.2)	9(47.4)	54(62.1)	57(77)	17(56.7)	0.029
d. Satisfaction with operative experience	67(32.2)	4(21)	27(31.8)	26(35.1)	10(33.3)	0.706
e. Satisfaction with didactic teaching	53(25.6)	5(40)	16(19)	21(28.8)	11(36.7)	0.465
f. Residency training too long	104(66.8)	8(61.5)	46(67.6)	31(62)	19(70.4)	0.950
aTotals may not add to indicated sum due to missing values.
bComparison of various age groups, calculated by χ2- test.

Table 3c. Analysis of Strongly agree/Agree Responses to selected Items by 5 Main Dental Specialties.

Item	No (%)of all Respondents(N=214)a	Oral/Max Surg (N=68)	Cons (N=30)	Paedo (N=16)	Ortho (N=34)	OM (N=16)	P Valueb
a. Training programme has adequate support structures	50(31.1)	20(29.4)	7(23.3)	3(18.7)	18(54.5)	2(12.5)	0.014
b. Support from department/faculty member	101(62.7)	46(67.6)	16(60)	11(68.8)	21(63.6)	7(46.6)	0.504
c. Need for training after completion of residency	102(62.6)	44(64.7)	19(63.3)	9(56.3)	22(64.7)	8(53.3)	0.487
d. Satisfaction with operative experience	59(36.9)	26(38.2)	8(28.6)	5(35.7)	18(52.9)	2(12.5)	0.022
e. Satisfaction with didactic teaching	39(24.5)	22(32.3)	4(14.3)	1(6.7)	12(36.4)	0	0.022
f. Residency training too long	73(65.2)	9(45)	18(69.2)	12(75)	24(70.6)	10(62.5)	0.055
aTotals may not add to indicated sum due to missing values
bComparison among 5 main specialties of dental surgeon residents, calculated by χ2- test or Fischer’s test as appropriate.
Abbreviations: Oral/Max- Oral and maxillofacial surgery, Cons- Conservative dentistry, Paedo- Paedodontics, Ortho- Orthodontics, OM- Oral medicine.

Discussion

This PETARD study intended to describe the demographics of dental surgeons pursuing residency programmes in Nigeria and their professional expectations, experiences and attitudes towards the programme. It was also to provide insights into the relationship between some demographic characteristics and the expectations, experiences and attitudes. In the earlier study5 of Nigerian general surgery residents, most (72.7%) were between 30-39 years of age which was similar to our finding (76.4%) from Table 1a. This was more than the proportion of United States general surgery residents in the same age group (55.6%) according to Yeo et al3. Those aged 40years and older in the US study were 10.4% as compared to 49.1% of Nigerian dentistry residents as shown in Table 1a. This implied that Nigerian dentists and general surgeons commenced residency training at an older age when compared to the general surgery residents in the USA. Possible reasons could be that students commence undergraduate training at older ages, stay too long due to incessant strikes and other disruptions of academic work or commence residency training at an older age in Nigeria. Further work is recommended to determine the causes and effects of entering residency training at an older age in Nigeria especially on the quality of residents and their ability to cope with the training programme.

In Nigeria, previous reports on surgery residents showed a preponderance of males (92.4%- 96.6%) over females (3.4%-7.6%)4,5. In the paper by Yeo et al3 , the female representation among USA general surgery residents was more favourable (31.7%). On the other hand; there has been a report on the feminization of dentistry11. This was supported by a previous Nigerian study of dentists that reported more females than males (54.5% vs 45.5%)12. Our results indicated a fair female presence among dental residents in Nigeria with 34.8% in Table 1a. However, female dental residents were disproportionately more in the orthodontic, conservative dentistry and paedodontics specialties in our study. The sample selection method adopted by Isiekwe and co-workers, 12, could have favoured more female representation, but our results on gender distribution more likely reflected the situation in Nigeria. This is buttressed by the national coverage and larger sample size of this study. There is need for further research into training and work factors that could improve gender representation in the various dental specialties for better public perception of dentistry as a profession.

Despite the importance of the fair distribution of specialists in various aspects of dentistry for optimal service delivery, there is scarce data about this distribution and its determining factors. International comparison of the distribution pattern is further hampered by national differences in the nomenclature of dental specialties. In the U.S.A, there are 9 dental specialties with orthodontics as the most populous13whilst in the U.K., there are 13 dental specialties recognised by the General Dental Council of which orthodontics followed by oral surgery were predominant 14. The Kingdom of Saudi Arabia reportedly has 15 dental specialties according to Halawany et al., 15. In our survey across all accredited training institutions for dental surgeons in Nigeria, ten specialties were identified with most residents in oral and maxillofacial surgery (31.8%) followed by orthodontics (15.9%) and conservative dentistry (14%) as listed in Table 1b. Our findings corroborate the earlier reports from Ibadan and Lagos, Nigeria that showed graduates of dentistry preferred residency specialisation in oral and maxillofacial surgery followed by orthodontics and conservative dentistry. Few dentistry graduates from Nigeria in these studies were interested in the other specialties16, 17. Among dental students in Saudi Arabia, the preferences for postgraduate specialisation were restorative/aesthetic dentistry, endodontics, prosthodontics. orthodontics and oral/maxillofacial surgery in that order15. There is need for international standardisation of dental specialties to ease comparability. The relative distribution of dental specialties and specialists in various countries could be indicative of national licensing requirements for the specialisation, prestige, earning potential, availability of trainers and infrastructure. Presently, not all dental specialist training is available in Nigeria, hence there is need for local capacity for residency training in dental radiology for example.

In earlier studies of non- dental Nigerian residents4,5, there were more junior (74.9%-89.1%) than senior residents indicating positive interest in pursuing specialist residency training. Table 1b showed about 54% junior dentistry residents which was much lower than the findings among Nigerian surgery residents. The relatively higher proportion of senior dental residents (44.5%) at Part One level is worrisome as it reflects possible stagnation at this level. Furthermore, in Table 1b, 25.5% of dental residents had spent 6years or more in the programme when the maximum duration ought to be 6years. This contrasts with 15.9% of general surgery residents being 6 or more years in the training programme in Nigeria5. Reasons could be trainee, trainer or curriculum related. However, stagnation could be frustrating experience to these senior dental residents and their trainers, discourage others from entering the programme and make gaining practical experience difficult for junior residents. There is need for residency trainers at the dental faculty of the postgraduate colleges to re-examine and remedy intricate factors causing stagnation at Part One level.

The expectations, experiences and attitudes of trainee dental surgeons were evaluated in this PETARD study. Dental residents expressed low level of satisfaction (30.2%) with the quality of their training as shown in Table 2. There were no previous literature on satisfaction with residency training among all dental specialties for comparison but our result contrasted to the high level of satisfaction (85.2%) expressed by general surgery residents in the U.S.A3. The low level of satisfaction in Nigeria could be a reflection of the training curriculum, the state of infrastructure in the training institutions and/or the conduct of the trainees/trainers. The poor state of government health facilities in Nigeria including university teaching/specialist hospitals is already well known. There is urgent need for focused investment on the national health system. In addition, there is need to identify the motivating and demotivating factors among dental residents identified in this in order study to improve their level of satisfaction with training.

An important technical aspect of residency training is the self-confidence of the trainee. A moderate proportion of dental residents (45.2%) from Table 2 felt their operating skills were appropriate. This is much lower than the level among resident general surgeons in the U.S. according to Yeo et al3. With respect to the support structures by the training programme for struggling residents, Yeo et al3, found that 71.6% of residents were satisfied as compared to 30.3% in our study. There was satisfaction with operative experience among 31.9% of Nigerian dental surgery residents from our study but 76.4% of U.S. general surgery residents were satisfied in the report by the Yeo et al3. There seems to be generally low experience of didactic teaching among residents. While among general surgery residents, it was between 42.3%-52.6% 3,5, among dental residents, it was 25.4% from this study. Surgery is an art and a science; hence it is taught didactically, through mentorship and practical training. The relatively low level of technical experience from residency training among dental surgeons in this report confirms the poor level of satisfaction with training expressed earlier. There is need to improve the level of operating skill by restructuring the dental residency training curriculum to increase operating experience, and didactic teaching through scheduled lectures by consultants as part of the residency programme.

The human dimension of residency training encompasses those attributes that enable optimal functioning of the resident among family members and to successfully complete the programme. In the study by Yeo et al3, work stress caused strain in the family life of 30.7% of U.S. general surgery residents but affected more Nigerian residents (66.3%) in the same specialty according to Ojo et al5. Among Nigerian dental residents, 41.2% felt the same while 29.2% of dental residents considered leaving the programme in the last one year, among general surgeons, the rate was 15.3% 3.

Professional dimension reflects how the residents view the specialty and their place within it. Among general surgeons in the U.S. and Nigeria, 52.4%-55.5% disagreed with the view that duration of residency training was too long3,5. Table 2 showed that while 16.1% of dentistry residents disagreed that residency training was too long, 18.6% were neutral and 65.2% of dental residents felt their training took too long. While few (9%) were worried about the survival of their dental specialty in this study, 28.6% of general surgeons surveyed in the U.S. were worried about the same issue3. The concern about the duration of dentistry residency training Nigeria seen in this study could be related to stagnation at the level of Part One and the overall low level of satisfaction of residents about their training noticed earlier. The overall confidence in the survival of their dental specialty is a boost to the profession as it would ensure steady interest in residency specialisation in Nigeria despite the concern about duration.

Previous Nigerian studies on the expectations, experiences and attitudes of resident doctors towards their training did not adequately explore relationship between these and the demographic characteristics of respondents. This Nigerian study of dental surgery residents analysed the gender inclination towards some topics in Table 3a. There was more male satisfaction with the adequacy of support structures by the training programme, support from department/faculty members and the need for further training after residency training. More males were also satisfied with operative experience and didactic teaching and the belief that training duration was too long. Of these, there was statistically significantly more male support for satisfaction with didactic teaching (p=0.032) while support for other parameters were not statistically significant indicating broad support irrespective of gender. There was no comparable previous literature on dentistry residents on the relationship between gender and support for didactic teaching. The finding in Table 3a indicated that assessment and utilization of support structures by residents varied with gender and that didactic teaching was also appreciated in a different way between males and females. Further studies on these gender factors could assist residency trainers design support structures that are more accessible to females.

Table 3b showed there are age group differences among respondents to the same parameters earlier presented. However, these differences were statistically significant for those who needed further specialist training after completing residency (p=0.029). The dental residents aged 35-40 years expressed the most need (77%) to complete additional specialty training after completion of residency training in order to be competitive in the job market. They were closely followed by those aged 30-34 years (62.1%) and above 40 years (56.7%). While there are differences in the level, the general belief was that additional specialist training after residency was necessary. These strengthens the need for residency training to be commenced at an earlier age as it is done in more developed societies and provision of facilities to encourage continuing professional development.

The earlier selected parameters were also analysed by the five common dental specialties pursued by residents in this study (oral/maxillofacial surgery, conservative surgery, paedodontics, orthodontics and oral medicine). Table 3c showed there were no statistically significant differences among residents in these 5 dental specialties for the adequacy of support from departmental/faculty members to struggling residents, the need for further training after completion of residency training and that residency training was too long. Residents in paedodontics (68.8%) and oral and maxillofacial and orthodontics (64.7% each) expressed most support for these items respectively. With respect to adequacy of support structures put in place by the training programme for struggling residents, residents in orthodontics expressed greater support (54.4%) with statistical significance (p=0.014) than residents in other 4 specialties. Orthodontic residents expressed greatest satisfaction with operative experience gained during training (52.9%) than other residents in the other four specialties with statistical significance (p=0.001). Residents of the same specialty (orthodontics) also had highest level of didactic teaching (36.4%) with statistical significance (p=0.022) to the other specialties analysed. These findings should stimulate trainers of residents to evaluate the better practises of those in orthodontics for emulation across all specialties.

The postgraduate residency exams passed is an important indicator of the progress of training. Residents who have not passed any exam, passed primaries and Part One were analysed for their response to selected items of the questionnaire. Table 3d showed there were mild to marked differences in their responses. Residents who had passed primaries expressed the greatest belief (69.5%) that departmental/faculty members would support them while struggling than those who have passed Part One (64.1%) as against those who had not passed any exam (31.6%). These differences were statistically significant (p=0.021) reflecting better support of departmental/faculty members to those preparing for Part One exams at the expense of those yet to pass any exams who may not be technically regarded as residents. Part One residents expressed the greatest need (76.3%) for further specialist training after completing residency which was statistically significant (p=0.022) as compared to other residents. This indicates that till the dental resident has passed Part One, the need for post-residency training may not be a priority of the resident dental surgeon.

The study could have some potential limitations. Apart from being an index study among all dentistry residents nationwide, it explored sensitive issues that respondents could exhibit response bias by providing socially responsible replies, that may also accentuate negative opinions18. These were limited by distributing the study instrument through other residents, providing promises of confidentiality and making the questionnaire anonymous. In view of paucity of previous studies of this type, the study instrument was based on a previously validated tool by Yeo et al3, which was further tested and validated among Nigerian dental residents for content and sample validity. We reduced regional and specialty biases18 by enrolling all available residents at all centres and using the pooled results for this report. The use of 5-point Likert-type scale for responses ranging from strongly agree to strongly disagree could also elicit end aversion bias as some respondents would tend to avoid extreme ratings. We compensated for this possibility by merging strongly agree/ agree and strongly disagree/disagree in our results. Despite these possible limitations, our report had several strengths. The national spread and good response rate (93%) greatly reduced low motivation bias and enhanced its generalisability. Our use of a validated tool ensured that most aspects of the experiences, expectations and attitudes of residents were evaluated properly providing a baseline for similar studies worldwide.

Conclusions

Overall, this study showed that Nigerian dentistry residents had low level of satisfaction with the quality of their training which indicated the need for a holistic review of the training curriculum and conduct of trainers. There is need to reinforce motivating and tackle demotivating factors identified in this study to improve the response of dentistry residents to their training as these would improve the value of competency assessments undertaken by the postgraduate colleges while sustaining interest in the profession for the interest of the wider society.