Factors influencing timely graduate of cardiology residency study: an insight from single center university based residency program in Indonesia

Introduction

Indonesia is one of the most populous countries, with approximately 260 million people. According to World Bank data, in 2021, the doctor-to-population ratio was 0.7 per 1000 people, and in 2022, there were only 1,485 cardiologists in Indonesia.^1–3 To address this shortage, universities in Indonesia administer residency programs to support teaching hospitals and colleges involved in the selected study. The Indonesian Heart Association (IHA) serves as a college for cardiology residency. Despite the critical role of residency programs in producing competent cardiologists, the number of universities offering such programs remains limited. Only 13 universities in Indonesia, all state institutions, offer cardiology residency programs, including Padjadjaran University.⁴

The university-based residency program (UBRP) system grants universities the primary role in the student selection process. This process typically involves multiple screenings, such as grade point average (GPA) from a bachelor’s degree, English proficiency test, psychological test, academic test, and interview. The objective of this screening process is to select residents who perform well in both cognitive and non-cognitive assessments.^5,6

In addition to individual merits, the availability of residency positions also influences the admission process. With a limited number of slots available each year, the prolonged duration of residency training restricts the influx of new talent into the healthcare workforce and strains the resources and infrastructure of residency programs.² When residency slots remain occupied beyond the anticipated duration, the program’s ability to accommodate and support additional residents becomes compromised.

Timely graduation from residency is crucial for Indonesia’s residency programs. Unfortunately, data on the factors influencing timely graduation from residency programs, especially in Indonesia, are scarce. This study aimed to identify the factors influencing the length of the cardiology residency program.

Methods

This was a single-center, retrospective cohort study utilized admission data from Padjadjaran University (secondary data). This study has received ethical approval from the Hasan Sadikin Hospital Ethics Committee (Ethical Approval Number: LB.02.01/X.6.5/452/2023; 14 August 2023) and the Padjadjaran University Institutional Review Board. Approval from the hospital ethics committee was sought because the residency training program is conducted within Hasan Sadikin Hospital as the affiliated teaching hospital, and the data involved institutional clinical training records maintained under hospital governance. Written informed consent was obtained from all participants prior to data collection. Eligible participants were medical doctors who underwent residency training at Padjadjaran University between 2010 and 2015. Total sampling was applied, whereby all residents meeting the eligibility criteria during the study period were included. Exclusion criteria included missing data, dropouts, and internal medicine specialists who had already completed a cardiology subspecialty. The dataset comprised information collected during the selection process, including gender, age at selection, number of attempts, bachelor’s degree university, national service status, time of completion of bachelor’s degree, GPA, psychology test scores, English proficiency test scores, academic test scores, length of residency, interview scores, and duration of thesis defense.

Initially, applicants’ GPAs from medical school and clerkships were collected as separate variables and then averaged to yield a composite GPA score for each applicant. Scores from the psychology, academic, English proficiency, and interview tests were standardized for each applicant.

The primary outcome was the length of residency training. The length of residency was calculated based on the number of semesters each trainee completed from the start of residency training to graduation. Residents who completed the standard duration of eight semesters were categorized as timely graduates. In Indonesia, residents are required to submit and defend a scientific thesis as part of their residency program, with the standard timing for the thesis defense being no later than the seventh semester of their residency. Cases with missing data were excluded from analysis, and no data imputation was performed.

To minimize selection bias, total sampling included all eligible residents during the study period. Reliance on routinely gathered institutional admission and academic records reduced measurement bias through standardized testing protocols and established scoring methods. However, as a retrospective study, risks of information bias from incomplete documentation and residual confounding by unmeasured factors persist.

Results

A total of 66 residents were included in the study, of whom 34 (51.5%) were male, with a median age of 29 years (24–37 years). Most residents graduated from a public university (50 [75.8%]), and 39 (59.1%) completed their bachelor’s degree within 6 years. The mean GPAs for medical school, medical clerkship, and combined were 3.27 (0.32), 3.41 (0.22), and 3.34 (0.24), respectively. Thirty-four residents (51.5%) had previously completed national service. Detailed baseline characteristics are presented in Table 1. All included participants had complete data for the analyzed variables.

Most timely graduates were male (14 [70%]), which was statistically significant (OR 3.033, 95% CI 0.99–9.3, p = 0.048). The mean academic test score was higher in the timely graduate group [54.76 (9.17) vs. 46.48 (15.05), p = 0.008], while the median psychology test score was lower [60 (40–76) vs. 70.5 (40–88), p = 0.002]. The type of bachelor’s degree university (public) did not differ significantly between the groups [18 (90%) vs. 32 (69.6%), p=0.075]. The median age was also not significantly different [28 (25–37) vs. 27.5 (24–36), p = 0.320]. Additionally, there were no significant differences between the two groups regarding time to graduate, national service, medical school GPA, medical clerkship GPA, combined GPA, interview test, or English proficiency test scores (p = 0.671, p = 0.363, p = 0.701, p = 0.101, p = 0.834, p = 0.240, and p = 0.948, respectively). These findings are detailed in Table 2.

Similar results were observed when comparing the final thesis presentation groups. Only eight residents completed their final thesis presentation within the standard timeframe. The median psychology test score was lower for those who completed their thesis in seven semesters [60 (40–60) vs. 70 (40–88), p = 0.001]. There were no significant differences between the two groups in terms of sex, type of bachelor’s degree university, age, time to graduate, national service, medical school GPA, medical clerkship GPA, combined GPA, interview test, academic test, or English proficiency test. These results are summarized in Table 3.

Discussion

One notable aspect of our study was the relatively equal representation of male and female residents within our sample. This contrasts with trends observed in certain regions, such as the United States, where females account for only 13% of practicing cardiologists.⁷ Furthermore, our study found that male residents were more likely to graduate on time than their female counterparts. While no studies have specifically investigated gender and timely graduation among cardiology residents, our findings may align with research on emergency medicine residents, which shows higher milestone attainment throughout training for males with the same baseline performance.⁸ This discrepancy might be attributed to unrecognized gender bias during residency evaluations. Accordingly, a cross-sectional study conducted by Rogers et al., revealed that female residents reported being treated differently by supervisors and ancillary staff, with teams responding differently to them.⁹

Another important finding was the lack of significant differences in prior educational attainment, as reflected by GPA, between the timely and prolonged graduation groups. Both groups demonstrated similar performance in terms of GPAs during medical school and clerkship, as well as combined GPA. According to the AMEE guidelines, this could be attributed to discrepancies in university quality, which are variable and can disadvantage certain groups, leading to inconsistencies in educational outcomes.¹⁰ In Indonesia, public universities are generally perceived to perform better than private universities. This perception is supported by a study indicating that Clinical Performance Instrument (CPI) scores, an evaluation tool for new doctors’ clinical competence, are higher for medical students from public universities compared to those from private institutions. However, our study found no differences between the timely and prolonged graduate groups, which may be due to the lack of data on the accreditation status of each university, as accreditation can also influence performance.¹¹

The academic admission test provides standardized measurements for all applicants. In our study, higher academic test scores were observed in the timely graduate group compared to the prolonged group. This finding aligns with studies that have shown higher aptitude exam grades are associated with better academic performance, as reflected by GPA.^6,12,13 However, no studies have specifically investigated the relationship between aptitude exam grades and graduation timing. Additionally, our study found no statistically significant difference in interview scores between the two groups, which may be attributed to the lack of reliability in these scores.¹⁰

Psychological tests, commonly administered in the form of personality assessments, are frequently employed to evaluate applicants’ non-cognitive attributes. Research suggests a positive correlation between performance on these tests and residency scores, with specific traits demonstrating a potential for enhancing academic achievement when put into practice, as demonstrated by a previous study.¹⁴ Conversely, a systematic review encompassing 22 studies investigating the utilization of emotional intelligence (EI) revealed varied opinions regarding the suitability of personality assessment in medical student selection.¹⁵ These findings may be ascribed to conscientiousness exhibiting a negative association with assessments in medical school. Our study’s findings indicate that within our population, lower scores on psychological tests corresponded to better performance in terms of duration of study and thesis presentation. This inconsistency merits attention in future research endeavours.

Notably, only 8 residents (12.1%) managed to complete the thesis presentation within 7 semesters. This could potentially be attributed to a low baseline level of proficiency in medical writing skills; however, data regarding this variable are regrettably absent from our study. This observation may be underscored by SCImago data spanning the period from 1996 to 2022, revealing that the number of medical publications from Indonesia amounted to only 39,731, ranking the country 49th globally.¹⁶

This study has several limitations. Firstly, the retrospective design precludes the establishment of a causal relationship between the variables under investigation. Secondly, the relatively small sample size and the study’s single-center nature constrain the generalizability of our findings. Additionally, the final thesis presentation group was notably small.

Timely graduation was more common among males with higher academic test scores. Notably, prior academic performance did not exhibit significant variation between timely and prolonged graduates in our study. Intriguingly, the psychology test scores were lower in the graduated and final thesis groups, which presents a paradoxical finding. The low proportion of timely thesis presentations suggests challenges related to medical writing skills. Further research is imperative to enhance the outcomes of medical education in Indonesia.

Ethical considerations

The research has received ethical approval from the Hasan Sadikin Hospital Ethics Committee (Ethical Approval Number: LB.02.01/X.6.5/452/2023; 14 August 2023) and the Padjadjaran University Institutional Review Board. Approval from the hospital ethics committee was sought because the residency training program is conducted within Hasan Sadikin Hospital as the affiliated teaching hospital, and the data involved institutional clinical training records maintained under hospital governance. Written informed consent was obtained from all participants.