medical education aims to prepare medical students for clinical practice . educational environment is the most important factor effecting on students training and achievements ( 1 - 3 ) .
therefore , evaluating the educational setting can show defects in medical education and help to solve them ( 4 ) .
this study was designed for evaluating medical educational environment in a tertiary pediatric hospital in tehran , using an international questionnaire known as dundee ready educational environment measure ( dreem ) .
this instrument was used in several medical schools of different countries , such as sri lanka ( 5 ) , saudi arabia ( 4 , 6 , 7 ) , united arab emirates ( 8) , turkey ( 9 ) , germany ( 10 ) , sweden ( 11 ) , united kingdom ( 12 - 14 ) , and canada ( 15 , 16 ) for different types of undergraduate educational studies . in spite of excellent clinical services ,
there were many educational problems in this subspecialty referral pediatric center which was similar to other tertiary centers around the world ( 17 , 18 ) .
thus , we tried to address under - graduate educational deficits in this hospital and find feasible solutions .
in order to investigate whether these educational problems were student dependent , we examined the relation between students knowledge and their perception of this educational environment .
this cross - sectional study was done in the children s medical center , the pediatrics center of excellence in iran affiliated to tehran university of medical sciences during 2012 .
seventeen students did not fill the questionnaire ( response rate = 78% ) ; and therefore were excluded from the study .
knowledge of students is best determined by cumulative grade point average ( cgpa ) , medical students comprehensive basic sciences exam ( cbse ) score , and national university entrance exam ( known as konkoor ) rank ( 19 ) .
clerkship period ( before internship ) in tehran university of medical science lasts about 2.5 years ; during this period , 3 months are devoted to pediatrics .
the curriculum of pediatric course started with 2 weeks of classes and lectures ; then students are divided into 10 groups of 7 or 8 and each group spent a week in one specialized ward , including emergency department , infectious disease , neurology , immunology and rheumatology , gastrointestinal , hematology , cardiology , endocrinology , and neonatology . during each week
each day was planned for one teacher to train the group of students in ward or clinic .
we used dreem questionnaire for assessing the educational environment of this sub - specialty pediatric hospital .
it consists of 50 items divided into 5 categories : student perception of learning , 12 questions , student perception of teachers , 11 questions , student academic self - perception , 8 questions , student perception of atmosphere , 12 questions , and student social self - perception , 7 questions .
items were scored with likert scale as follows : 4 = strongly agree , 3 = agree , 2 = unsure , 1 = disagree , and 0 = strongly disagree .
two questions ( numbers 10 and 26 ) were changed slightly according to particular condition of this pediatric course .  
items scored above 3.5 have good condition ; those scored between 2 and 3.5 can be improved , while those less than 2 show areas of shortage and deficit .
guideline for interpretation of each subscale score is summarized in table 1 ( 21 ) . as most of the items had low scores and were placed in the weak category ( < 2 ) ,
we used first and third quartile as a cut - off ( 1.44 , 2.32 ) to select the most problematic and strongest items . translated version of dreem questionnaire was prepared previously by other researchers ( 22 ) .
construct validity was checked by confirmatory factor analysis which moderately fit with five predefined subscales .
the reliability of this questionnaire in our population was calculated with cronbach s alpha method .
the internal consistency of total items was 0.93 and of subscales 1 to 5 were 0.89 , 0.76 , 0.84 , 0.89 , and 0.7 , respectively .
the forms were anonymous ; also , there were five questions in advance of main questions , including gender , cgpa , cbse score , and konkoor rank .
sheets with open questions were also spread among students separately and comments were extracted and classified . before distribution of questionnaires the aim of the study was explained in a session and the students were asked to answer the questions according to their general view of this course rather than individual events .
kruskal - wallis h test was used to compare students based on their gpa , cbse , and konkoor ranks .
this cross - sectional study was done in the children s medical center , the pediatrics center of excellence in iran affiliated to tehran university of medical sciences during 2012 .
seventeen students did not fill the questionnaire ( response rate = 78% ) ; and therefore were excluded from the study .
in the iranian medical schools , knowledge of students is best determined by cumulative grade point average ( cgpa ) , medical students comprehensive basic sciences exam ( cbse ) score , and national university entrance exam ( known as konkoor ) rank ( 19 ) . clerkship period ( before internship ) in tehran university of medical science lasts about 2.5 years ; during this period , 3 months are devoted to pediatrics .
the curriculum of pediatric course started with 2 weeks of classes and lectures ; then students are divided into 10 groups of 7 or 8 and each group spent a week in one specialized ward , including emergency department , infectious disease , neurology , immunology and rheumatology , gastrointestinal , hematology , cardiology , endocrinology , and neonatology . during each week
each day was planned for one teacher to train the group of students in ward or clinic .
we used dreem questionnaire for assessing the educational environment of this sub - specialty pediatric hospital .
it consists of 50 items divided into 5 categories : student perception of learning , 12 questions , student perception of teachers , 11 questions , student academic self - perception , 8 questions , student perception of atmosphere , 12 questions , and student social self - perception , 7 questions .
items were scored with likert scale as follows : 4 = strongly agree , 3 = agree , 2 = unsure , 1 = disagree , and 0 = strongly disagree . some items were negative questions ; thus they were coded reversely .
two questions ( numbers 10 and 26 ) were changed slightly according to particular condition of this pediatric course .  
items scored above 3.5 have good condition ; those scored between 2 and 3.5 can be improved , while those less than 2 show areas of shortage and deficit .
guideline for interpretation of each subscale score is summarized in table 1 ( 21 ) . as most of the items had low scores and were placed in the weak category ( < 2 ) ,
we used first and third quartile as a cut - off ( 1.44 , 2.32 ) to select the most problematic and strongest items . translated version of dreem questionnaire was prepared previously by other researchers ( 22 ) .
construct validity was checked by confirmatory factor analysis which moderately fit with five predefined subscales .
the reliability of this questionnaire in our population was calculated with cronbach s alpha method .
the internal consistency of total items was 0.93 and of subscales 1 to 5 were 0.89 , 0.76 , 0.84 , 0.89 , and 0.7 , respectively .
the forms were anonymous ; also , there were five questions in advance of main questions , including gender , cgpa , cbse score , and konkoor rank .
sheets with open questions were also spread among students separately and comments were extracted and classified . before distribution of questionnaires the aim of the study was explained in a session and the students were asked to answer the questions according to their general view of this course rather than individual events .
nonparametric tests were used to analyze the data . kruskal - wallis h test was used to compare students based on their gpa , cbse , and konkoor ranks .
among 60 students who answered the questionnaire 24 were male ( 40% ) and 36 were female ( 60% ) , aged from 23 to 24 years .
forty two ( 70% ) students had cgpa between 16 to 17.9 out of 20 ; nineteen ( 32% ) students gained cbse score between 120 to 139.9 out of 200 , and 23 ( 38% ) of them had konkoor rank of less than 50 ( table 2 ) .  
abbreviations : cbse , comprehensive basic science exam , cgpa , cumulative grade point average ; sd , standard deviation .
the least ( l ) and most ( m ) scored items in each subscale are as follows : learning category : l :  the teaching is too teacher centered .  was weakest .
 m :  learning strategies which worked for me before , continue to work for me now .
 atmosphere category : l :  the atmosphere motivates me as a learner .  m :  i feel able to ask the questions i want .  social self - perception category : l : 
comparison between different cgpa , cbse , and konkoor groups showed no considerable difference ( p value > 0.05 ) .
although there is no published study comparing clinical skills of medical students in tehran university of medical sciences with other universities , according to konkoor ranks and cbse scores , it could be noted that they are the best among their peers in iran . considering that , educational environment of this subspecialty pediatric hospital obtained a mean total score of 95.8 .
as said by mcaleer and roff ( 21 ) this score enlightens plenty of problems in educational environment . besides , we found that both weak and strong students with low and high cgpa , cbse , and konkoor rank were dissatisfied with this educational environment ; emphasizing that these problems were not related to students incompetency . in comparison to most of studies surveying whole courses of undergraduate education ,
therefore , comparing it with other studies in different countries is roughly inferable ; nevertheless they are summarized in table 6 . by means of mcaleer and roff guideline ( 21 ) ,
teacher  moving in the right direction  , academic self - perception has  many negative aspects 
, atmosphere has  many issues which need changing  , and social self - perception is  not a nice place  . in order to discuss about the strengths and weaknesses , we used the individual item scores in each subscale . learning : consecutive lecture - based classes conveying large amount of information , made the theory classes unsatisfactory , as was shown by low scores in items 7 , 13 , 25 , 44 , 48 and found in students comments ( tables 4 and 5 ) .
regarding that all items in this section scored below the third quartile ( less than 2.32 ) , fundamental reforms should be made .
teacher : high scores in items 2 , 8 , 18 , 37 , 39 , 49 , and 50 ( table 4 ) elucidate that there are knowledgeable and experienced pediatricians in this center , practicing scientifically and making moral interaction with students and patients .
academic self - perception : there was lack of an explicit plan to prepare students for general practice .
also most of the lectures and rounds were pertained to subspecialty issues and rare cases , as low scores in 22 , 26 , and 41 items ( table 4 ) .
atmosphere : items 33 and 50 ( table 4 ) showed that students were able to interact with their teachers easily ; however , the atmosphere of classes and rounds were not motivating , as shown by item 43 ( table 4 ) .
other important de - motivating factors were stressful attendance checking and authoritarian educational office , as was also noted in students comments ( table 5 ) .
numerous tasks of attending caused interference between their educational activity and the written timetable , explaining low score in item 12 .
social self - perception : because of 3 months of tight classes , large amount of tasks and two heavy exams with limited time to prepare , students became jaded , as shown by item 14 ( table 4 ) .
low score in item 3 is due to lack of friendly relationship between teachers and students out of teaching classes , which led students to feel ineffective and having no social supports ( table 4 ) .
we believe that most of these mentioned educational problems are due to subspecialty nature of this center .
many studies showed advantages of medical education in general practice setting versus tertiary referral hospitals ( 18 , 28 - 30 ) .
learning medicine in general view , engagement in medical team , doing some clinical tasks and following patients are explained reasons for this preference . we think that training students for general practice needs separate setting in this tertiary hospital ; for instance , making 1 or 2 general pediatric wards may be helpful . at last ,
the results were discussed with manager and attending of this hospital and few changes were made in the curriculum .
limitation of our study was small number of participants , short period of this course and inability to reevaluate perception of this group of students after modification of curriculum .
precise distribution of questionnaire , non - parametric analysis of our data , good cooperation of students for giving comments , and discussing it to hospital authorities were the strengths of our study .
further studies on subsequent semesters and modifying the environment and re - evaluation of the program can improve this educational environment . in spite of excellent pediatric health care , several educational problems could be noted in this tertiary pediatric center .
the most problematic areas were learning , academic self - perception , and social self - perception .
feasible solutions for improving this educational setting are having an accurate schedule to educate general practitioner by emphasizing on the most prevalent necessary subjects , using new teaching methods that involve students , and providing a non - stressful and friendly atmosphere .
this study can be used as a baseline to be compared with new curriculum and educational reforms .
 background : tertiary pediatric hospitals usually provide excellent clinical services , but such centers have a lot to do for educational perfection.objectives:this study was performed to address under - graduate educational deficits and find feasible solutions.patients and methods : this cross - sectional study was done in a target population of 77 sixth year undergraduate medical students ( response rate = 78% ) who spent their 3-month pediatric rotation in the children s medical center , the pediatrics center of excellence in tehran , iran . 
 the dundee ready educational environment measure ( dreem ) instrument was used for assessing educational environment of this subspecialized pediatric hospital.results:among 60 students who answered the questionnaires , 24 were male ( 40% ) . 
 participants age ranged from 23 to 24 years . 
 the mean total score was 95.8 ( 48% ) . 
 comparison of scores based on students knowledge showed no significant difference . 
 problematic areas were learning , academic self - perception , and social self-perception.conclusions:having an accurate schedule to train general practitioner , using new teaching methods , and providing a non - stressful atmosphere were suggested solutions . 
1. Background
2. Objectives
3. Patients and Methods
3.1. Participants
3.2. Medical Setting
3.3. Instrument
3.4. Statistical Analysis
4. Results
5. Discussion