Initial use of a novel instrument to measure professionalism in surgical residents

A modified Delphi approach to nurturing professionalism in postgraduate medical education in Singapore

INTRODUCTION

Nurturing professional identities instils behavioural standards of physicians, and this in turn facilitates consistent professional attitudes, practice and patient care. Identities are socioculturally constructed efforts; therefore, we must account for the social, cultural and local healthcare factors that shape physicians' roles, responsibilities and expectations. This study aimed to forward a programme to nurture professionalism among physicians in Singapore.

METHODS

A three-phase, evidenced-based approach was used. First, a systematic scoping review (SSR) was conducted to identify professionalism elements. Second, a questionnaire was created based on the findings of the SSR. Third, a modified Delphi approach, which involved local experts to identify socioculturally appropriate elements to nurture professionalism, was used.

RESULTS

A total of 124 articles were identified from the SSR; these articles revealed definitions, knowledge, skills and approaches to nurturing professionalism. Through the modified Delphi approach, we identified professional traits, virtues, communication, ethical, self-care, teaching and assessment methods, and support mechanisms.

CONCLUSION

The results of this study formed the basis for a holistic and longitudinal programme focused on instilling professional traits and competencies over time through personalised and holistic support of physicians. The findings will be of interest to medical communities in the region and beyond.

Predicting Performance at Graduation From Early ACGME Milestone Ratings: Longitudinal Learning Analytics in Professionalism and Communication in Vascular Surgery

OBJECTIVE

Program directors in surgical disciplines need more tools from the ACGME to help them use Milestone ratings to improve trainees' performance. This is especially true in competencies that are notoriously difficult to measure, such as professionalism (PROF) and interpersonal and communication skills (ICS). It is now widely understood that skills in these two areas have direct impact on patient care outcomes. This study investigated the potential for generating early predictors of final Milestone ratings within the PROF and ICS competency categories.

DESIGN

This retrospective cohort study utilized Milestone ratings from all ACGME-accredited vascular surgery training programs, covering residents and fellows who completed training in June 2019. The outcome measure studied was the rate of achieving the recommended graduation target of Milestone Level 4 (possible range: 1-5), while the predictors were the Milestone ratings attained at earlier stages of training. Predictive probability values (PPVs) were calculated for each of the 3 PROF and two ICS sub-competencies to estimate the probability of trainees not reaching the recommended graduation target based on their previous Milestone ratings.

SETTING

All ACGME-accredited vascular surgery training programs within the United States.

PARTICIPANTS

All trainees completing a 2 year vascular surgery fellowship (VSF) in June 2019 (n = 119) or a 5 year integrated vascular surgery residency (IVSR) in June 2019 (n = 52) were included in the analyses.

RESULTS

The overall rate of failing to achieve the recommended graduation target across all PROF and ICS sub-competencies ranged from 7.7% to 21.8% of all trainees. For trainees with a Milestone rating at ≤ 2.5 with 1 year remaining in their training program, the predictive probability of not achieving the recommended graduation target ranged from 37.0% to 71.5% across sub-competencies, with the highest risks observed under PROF for "Administrative Tasks" (71.5%) and under ICS for "Communication with the Healthcare Team" (56.7%).

CONCLUSIONS

As many as 1 in 4 vascular surgery trainees did not achieve the ACGME vascular surgery Milestones targets for graduation in at least one of the PROF and ICS sub-competencies. Biannual ACGME Milestone assessment ratings of PROF and ICS during early training can be used to predict achievement of competency targets at time of graduation. Early clues to problems in PROF and ICS enable programs to address potential deficits early in training to ensure competency in these essential non-technical skills prior to entering unsupervised practice.

Use of the Behavior Assessment Tool in 18 Pilot Residency Programs

Background

The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism.

Methods

Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association's Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results.

Results

Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more < level 3 scores in a domain) and who also scored "below expectations" by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%).

Conclusions

The ABOSBT was able to identify 2.4% low score evaluations (<level 3) for all residents. The tool was concordant with the PD for 81% of the residents considered low performers or "outliers" for professional behavior. The 5-domain construct makes it an effective actionable tool that can be used to help develop performance improvement plans for residents.

Level of Evidence

Level II.

Nurturing professionalism in medical schools. A systematic scoping review of training curricula between 1990-2019

Introduction: Professionalism is an evolving, socioculturally informed multidimensional construct that influences doctor-patient relationships, patient satisfaction and care outcomes. However, despite its clinical significance there is little consistency in how professionalism is nurtured amongst medical students. To address this gap a systemic scoping review of nurturing professionalism in medical schools, is proposed.Methods: Levac's framework and the PRISMA-P 2015 checklist underpinned a 6-stage systematic review protocol. Concurrent use of Braun and Clarke's approach to thematic analysis and directed content analysis was used to identify the key elements in nurturing professionalism.Results: 13921 abstracts were identified from six databases, 854 full-text articles reviewed, and 162 full-text included articles were included. The 4 themes identified through thematic analysis are consistent with findings of the directed content analysis. These were the definition of professionalism, the approaches, content, barriers and enablers to teaching professionalism.Conclusion: Informed by a viable definition of professionalism and clear milestones nurturing professionalism nurturing professionalism begins with culturally appropriate training in clinical competence, humanistic qualities and reflective capacity. This process requires effective evaluations of professional identity formation, and the impact of the learning environment underlining the need for longitudinal assessments of the training process.

Orthopaedic Surgery Residency Milestones: Initial Formulation and Future Directions

Milestones specific to orthopaedic surgical training document individual resident progress through skill development in multiple dimensions. Residents increasingly interact with and are assessed by surgeons in both academic and private practice environments. Milestones describe the skills that support competence. One of the primary goals of milestones is to provide continuous data for educational quality improvement of residency programs. They provide a dialogue between surgeons who supervise residents or fellows and the program's Clinical Competency Committee throughout a resident's education. The orthopaedic milestones were developed jointly by the Accreditation Council for Graduate Medical Education and the American Board of Orthopaedic Surgery. The working team was designed with broad representation within the specialty. The milestones were introduced to orthopaedic residencies in 2013. Orthopaedics is a 5-year training program; the first comprehensive longitudinal data set is now available for study. This summary provides historical perspective on the development of the milestones, state of current milestone implementation, attempts to establish validity, challenges with the milestones, and the development of next-generation assessment tools.

Assessing Professionalism in Medicine - A Scoping Review of Assessment Tools from 1990 to 2018

BACKGROUND

Medical professionalism enhances doctor-patient relationships and advances patient-centric care. However, despite its pivotal role, the concept of medical professionalism remains diversely understood, taught and thus poorly assessed with Singapore lacking a linguistically sensitive, context specific and culturally appropriate assessment tool. A scoping review of assessments of professionalism in medicine was thus carried out to better guide its understanding.

METHODS

Arksey and O'Malley's (2005) approach to scoping reviews was used to identify appropriate publications featured in four databases published between 1 January 1990 and 31 December 2018. Seven members of the research team employed thematic analysis to evaluate the selected articles.

RESULTS

3799 abstracts were identified, 138 full-text articles reviewed and 74 studies included. The two themes identified were the context-specific nature of assessments and competency-based stages in medical professionalism.

CONCLUSIONS

Prevailing assessments of professionalism in medicine must contend with differences in setting, context and levels of professional development as these explicate variances found in existing assessment criteria and approaches. However, acknowledging the significance of context-specific competency-based stages in medical professionalism will allow the forwarding of guiding principles to aid the design of a culturally-sensitive and practical approach to assessing professionalism.

A Systematic Review of the Quality and Utility of Observer-Based Instruments for Assessing Medical Professionalism

BACKGROUND

Professionalism, which encompasses behavioral, ethical, and related domains, is a core competency of medical practice. While observer-based instruments to assess medical professionalism are available, information on their psychometric properties and utility is limited.

OBJECTIVE

We systematically reviewed the psychometric properties and utility of existing observer-based instruments for assessing professionalism in medical trainees.

METHODS

After selecting eligible studies, we employed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria to score study methodological quality. We identified eligible instruments and performed quality assessment of psychometric properties for each selected instrument. We scored the utility of each instrument based on the ability to distinguish performance levels over time, availability of objective scoring criteria, validity evidence in medical students and residents, and instrument length.

RESULTS

Ten instruments from 16 studies met criteria for consideration, with studies having acceptable methodological quality. Psychometric properties were variably assessed. Among 10 instruments, the Education Outcomes Service (EOS) group questionnaire and Professionalism Mini-Evaluation Exercise (P-MEX) possessed the best psychometric properties, with the P-MEX scoring higher on utility than the EOS group questionnaire.

CONCLUSIONS

We identified 2 instruments with best psychometric properties, with 1 also showing acceptable utility for assessing professionalism in trainees. The P-MEX may be an option for program directors to adopt as an observer-based instrument for formative assessment of medical professionalism. Further studies of the 2 instruments to aggregate additional validity evidence is recommended, particularly in the domain of content validity before they are used in specific cultural settings and in summative assessments.

Older and wiser? Changes in unprofessional content on urologists' social media after transition from residency to practice

OBJECTIVE

To characterize changes in the frequency and nature of unprofessional content on urologists' Facebook accounts during the transition from residency to practice.

METHODS

Facebook was queried with the names of all 2015 US urology graduates 1 year after completion of residency. We identified unprofessional and potentially objectionable content on the public Facebook accounts using a rubric based on professionalism guidelines by the American Urological Association, the American Medical Association and the Accreditation Council for Graduate Medical Education. Comparisons of unprofessional content were made with data from this cohort collected at the completion of residency. To assess how professional identities were reflected on social media, we determined which urologists self-identified as a urologist on Facebook and any changes in their unprofessional content.

RESULTS

Of 281 urologists, 198 (70%) had publicly identifiable Facebook accounts. Of these, 85 (43%) contained any unprofessional or potentially objectionable content, including 35 (18%) with explicitly unprofessional content. Examples included images of and references to intoxication, explicit profanity, and offensive comments about patients. Of the 201 Facebook accounts that had been publicly identifiable at the completion of residency, most profiles (182, 91%) had remained public; of the 19 that were no longer public, about half had previously contained unprofessional content. Similarly, of the 80 urologists without public profiles 1 year previously, most (64, 80%) had remained unidentifiable on Facebook; of the 16 accounts that had since become publicly identifiable, half had unprofessional content. Among the urologists on Facebook overall, 11 (6%) had posted new unprofessional or potentially objectionable content since entering practice. Comparing this cohort in practice vs at the completion of residency, there were no significant differences in how many urologists had public Facebook accounts (70% vs 71%) or whose accounts had concerning content (43% vs 40%). The presence of unprofessional content at the completion of residency strongly predicted having unprofessional content later in practice. More urologists overall self-identified as being a urologist on Facebook, and a larger proportion of these profiles also displayed unprofessional content (53% vs 47% 1 year previously).

CONCLUSION

Most urologists maintained public Facebook accounts after the transition to practice, and about half of these contained unprofessional or potentially objectionable content. Amidst their increasing self-identification as urologists on social media, the majority of practising urologists had posted concerning content, which could have an impact on their professional identities and public perceptions of the specialty.

Assessing medical professionalism: A systematic review of instruments and their measurement properties

Background

Over the last three decades, various instruments were developed and employed to assess medical professionalism, but their measurement properties have yet to be fully evaluated. This study aimed to systematically evaluate these instruments’ measurement properties and the methodological quality of their related studies within a universally acceptable standardized framework and then provide corresponding recommendations.

Methods

A systematic search of the electronic databases PubMed, Web of Science, and PsycINFO was conducted to collect studies published from 1990–2015. After screening titles, abstracts, and full texts for eligibility, the articles included in this study were classified according to their respective instrument’s usage. A two-phase assessment was conducted: 1) methodological quality was assessed by following the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist; and 2) the quality of measurement properties was assessed according to Terwee’s criteria. Results were integrated using best-evidence synthesis to look for recommendable instruments.

Results

After screening 2,959 records, 74 instruments from 80 existing studies were included. The overall methodological quality of these studies was unsatisfactory, with reasons including but not limited to unknown missing data, inadequate sample sizes, and vague hypotheses. Content validity, cross-cultural validity, and criterion validity were either unreported or negative ratings in most studies. Based on best-evidence synthesis, three instruments were recommended: Hisar’s instrument for nursing students, Nurse Practitioners’ Roles and Competencies Scale, and Perceived Faculty Competency Inventory.

Conclusion

Although instruments measuring medical professionalism are diverse, only a limited number of studies were methodologically sound. Future studies should give priority to systematically improving the performance of existing instruments and to longitudinal studies.

Parting the Clouds: Three Professionalism Frameworks in Medical Education

Current controversies in medical education associated with professionalism, including disagreements about curriculum, pedagogy, and assessment, are rooted in part in the differing frameworks that are used to address professionalism. Three dominant frameworks, which have evolved in the medical education community, are described. The oldest framework is virtue based and focuses on the inner habits of the heart, the development of moral character and reasoning, plus humanistic qualities of caring and compassion: The good physician is a person of character. The second framework is behavior based, which emphasizes milestones, competencies, and measurement of observable behaviors: The good physician is a person who consistently demonstrates competence in performing patient care tasks. The third framework is identity formation, with a focus on identity development and socialization into a community of practice: The good physician integrates into his or her identity a set of values and dispositions consonant with the physician community and aspires to a professional identity reflected in the very best physicians. Although each professionalism framework is useful and valid, the field of medical education is currently engaged in several different discourses resulting in misunderstanding and differing recommendations for strategies to facilitate professionalism. In this article, the assumptions and contributions of each framework are described to provide greater insight into the nature of professionalism. By examining each discourse in detail, underlying commonalities and differences can be highlighted to assist educators in more effectively creating professionalism curricula, pedagogy, and assessment.

Accounting for professionalism: an innovative point system to assess resident professionalism

BACKGROUND

Professionalism is a core competency for residency required by the Accreditation Council of Graduate Medical Education. We sought a means to objectively assess professionalism among internal medicine and transitional year residents.

INNOVATION

We established a point system to document unprofessional behaviors demonstrated by internal medicine and transitional year residents along with opportunities to redeem such negative points by deliberate positive professional acts. The intent of the policy is to assist residents in becoming aware of what constitutes unprofessional behavior and to provide opportunities for remediation by accruing positive points. A committee of core faculty and department leadership including the program director and clinic nurse manager determines professionalism points assigned. Negative points might be awarded for tardiness to mandatory or volunteered for events without a valid excuse, late evaluations or other paperwork required by the department, non-attendance at meetings prepaid by the department, and inappropriate use of personal days or leave. Examples of actions through which positive points can be gained to erase negative points include delivery of a mentored pre-conference talk, noon conference, medical student case/shelf review session, or a written reflection.

RESULTS

Between 2009 and 2012, 83 residents have trained in our program. Seventeen categorical internal medicine and two transitional year residents have been assigned points. A total of 55 negative points have been assigned and 19 points have been remediated. There appears to be a trend of fewer negative points and more positive points being assigned over each of the past three academic years.

CONCLUSION

Commitment to personal professional behavior is a lifelong process that residents must commit to during their training. A professionalism policy, which employs a point system, has been instituted in our programs and may be a novel tool to promote awareness and underscore the merits of the professionalism competency.

A framework for professionalism in surgery: what is important to medical students?

BACKGROUND

The purposes of this study were to develop a comprehensive framework for professionalism in surgery and to determine which attributes are most valued by medical students.

METHODS

A framework for professionalism in surgery, consisting of 11 attribute categories, was developed. All 3rd-year medical students (n = 168) participated in a focus group and completed a questionnaire regarding their perceptions about professionalism. Students' responses were transcribed verbatim, coded, and assigned attribute categories.

RESULTS

Students rated respect as the most important attribute of professionalism (56%), followed by altruism (21%) and interpersonal skills (8%). Fifty-three percent of students witnessed unprofessional behavior among faculty members while on the surgical clerkship. Of these incidents, 74% were related to respect, 28% to practice improvement, and 1% to altruism.

CONCLUSIONS

Respect was rated as the single most important characteristic of professionalism and was the attribute with the most witnessed violations.

Colorectal surgeons teaching general surgery residents: current challenges and opportunities

Effective teaching for general surgery residents requires that faculty members with colorectal expertise actively engage in the education process and fully understand the current context for residency training. In this article, we review important national developments with respect to graduate medical education that impact resident supervision, curriculum implementation, resident assessment, and program evaluation. We argue that establishing a culture of respect and professionalism in today's teaching environment is one of the most important legacies that surgical educators can leave for the coming generation. Faculty role modeling and the process of socializing residents is highlighted. We review the American College of Surgeons' Code of Professional Conduct, summarize some of the current strategies for teaching and assessing professionalism, and reflect on principles of motivation that apply to resident training both for the trainee and the trainer.

Integrating professionalism into the curriculum: AMEE Guide No. 61

Professional values and behaviours are intrinsic to all medical practice, yet remain one of the most difficult subjects to integrate explicitly into a curriculum. Professionalism for the twenty-first century raises challenges not only to adapting the course to changing societal values but also for instilling skills of ongoing self-directed continuous development in trainees for future revalidation. This Guide is based on the contemporary available literature and focuses on instilling Professionalism positively into both undergraduate and postgraduate training deliberately avoiding the more negative aspects of Fitness to Practise. The literature on Professionalism is extensive. An evidence-based approach has been taken throughout. We have selected only some of the available publications to offer practical advice. Comprehensive reviews are available elsewhere (van Mook et al. 2009a-g). This Guide takes a structured stepwise approach and sequentially addresses: (i) agreeing an institutional definition, (ii) structuring the curriculum to integrate learning across all years, (iii) suggesting learning models, (iv) harnessing the impact of the formal, informal and hidden curricula and (v) assessing the learning. Finally, a few well-evaluated case studies for both teaching and assessment have been selected to illustrate our recommendations.

[Medical ethics teaching]

In most European countries, medical ethics has become a more or less established subject in medical school curricula. Accordingly, the need to evaluate its success has arisen. In our paper, we describe the controversial debate about the proper goals of teaching medical ethics. Secondly, we present an overview of current efforts to measure and evaluate the outcome and effect of different medical ethics teaching programmes on medical students and young physicians. We conclude that medical ethics teaching is amenable to a great variety of teaching and evaluation methods. Finally, we argue that medical ethics teaching should include: (1) the teaching of moral reasoning skills, (2) the instruction about relevant ethical knowledge, as well as (3) the development of certain character traits. Methods to evaluate ethical knowledge and moral reasoning skills are readily available, while the evaluation of the development of character traits poses important conceptual difficulties.

Professionalism: self-control matters

BACKGROUND

Many of the behaviors that constitute professionalism require self-control.

AIM

To investigate the extent to which self-control is a component of resident professionalism, rated both by residents and their program directors.

METHODS

366 residents in 13 residency programs were invited to participate in a survey study of professionalism. Participating residents completed the Professionalism - Documentation of Competence (ProDOC) (a 15-item measure of professionalism developed for the study), a 10-item version of the Marlowe-Crowne Social Desirability Scale, and the Brief Self-Control Scale. Independently, program directors of participating residents completed the ProDOC with reference to each of their participating residents.

RESULTS

215 residents agreed to participate in the study (58.7% response rate). Resident ProDOC scores were significantly related to social desirability and self-control. Self-control alone accounted for approximately 25% of the variance in resident ProDOC scores, and approximately 17% of the variance in ProDOC scores when shared variance with social desirability was controlled. There was no correlation between resident and program director ProDOC scores.

CONCLUSIONS

Self-control is an important facet of human behavior and interpersonal interaction, including the behaviors that constitute medical professionalism. The lack of correlation between residents' self-ratings of professionalism and their program directors' ratings underscores the difficulty in understanding and measuring this competency.

Doctors in acute and longitudinal care specialties emphasise different professional attributes: implications for training programmes

OBJECTIVES

Organised medicine mandates that professionalism be taught during specialty training. This study's primary objective was to determine the relative importance that doctors in different specialties place on different attributes of a medical professional.

METHODS

Attending staff and resident doctors in acute care (anaesthesia, emergency medicine, surgery) and longitudinal care (internal medicine, psychiatry) specialties at a large academic hospital completed an anonymous, web-based survey. The forced-choice format required respondents to narrow down 25 professional attributes to three. The main outcome measure was the number of doctors in the two specialty groups who chose one or more attributes in each of six underlying categories.

RESULTS

Almost two-thirds of respondents in both groups chose Moral and Ethical attributes. Significantly more longitudinal than acute care doctors chose Relationships with Patients attributes (76% versus 58%) and Communication Skills attributes (28% versus 18%), whereas significantly more acute care doctors chose Clinical Competence attributes (44% versus 29%). Specialty group was more important in choice of professional attributes than gender or position as a resident or attending staff doctor.

CONCLUSIONS

Most respondents chose attributes that the literature and organised medicine define as core elements of medical professionalism. The differences between specialty groups suggest that attributes in the Relationships with Patients and Communication Skills categories be emphasised for trainees in acute care specialties, and attributes in the Clinical Competence category be emphasised for trainees in longitudinal care specialties.

A blueprint to assess professionalism: results of a systematic review

PURPOSE

Assessing professionalism is hampered by varying definitions and these definitions' lack of a clear breakdown of the elements of professionalism into aspects that can be measured. Professionalism is multidimensional, so a combination of assessment tools is required. In this study, conducted during 2007-2008, the authors aimed to match assessment tools to definable elements of professionalism and to identify gaps where professionalism elements are not well addressed by existing assessment tools.

METHOD

The authors conducted literature reviews of definitions of professionalism and of relevant assessment tools, clustered the definitions of professionalism into assessable components, and clustered assessment tools of a similar nature. They then created a "blueprint" whereby the elements of professionalism are matched to relevant assessment tools.

RESULTS

Five clusters of professionalism were formed: adherence to ethical practice principles, effective interactions with patients and with people who are important to those patients, effective interactions with people working within the health system, reliability, and commitment to autonomous maintenance / improvement of competence in oneself, others, and systems. Nine clusters of assessment tools were identified: observed clinical encounters, collated views of coworkers, records of incidents of unprofessionalism, critical incident reports, simulations, paper-based tests, patients' opinions, global views of supervisor, and self-administered rating scales.

CONCLUSIONS

Professionalism can be assessed using a combination of observed clinical encounters, multisource feedback, patients' opinions, paper-based tests or simulations, measures of research and/or teaching activities, and scrutiny of self-assessments compared with assessments by others. Attributes that require more development in their measurement are reflectiveness, advocacy, lifelong learning, dealing with uncertainty, balancing availability to others with care for oneself, and seeking and responding to results of an audit.

Instruction and assessment of professionalism for surgery residents

Surgical professionalism is one of the core competencies for surgery residents. It focuses on professional responsibilities to patients and society. This report summarizes current literature on surgical professionalism to help surgical residency program directors organize appropriate instruction and assessment methods for their residents. The instructional design should be based on 14 key concepts of surgical professionalism outlined by the American College of Surgeons. The professionalism curriculum should be a mixture between faculty-identified concepts and resident input of context that those concepts apply. Surgical faculty should start the instruction with a lecture, which later leads to problem solving of cases related to surgical professionalism. Surgical faculty should integrate professionalism instruction in everyday practice in all clinical settings, using both structured and apprenticeship approaches. A comprehensive assessment of professionalism requires both a maximal and a typical performance assessment. The test of maximal performance in an Objective Structured Clinical Examination (OSCE) format is suggested for the assessment of professionalism in situations that do not occur often. The test of typical performance can be achieved with ratings from faculty, peers, nurses, and patients to evaluate professionalism competence in regular clinical services.

How resident unprofessional behavior is identified and managed: a program director survey

OBJECTIVE

To determine how unprofessional behavior by residents is identified/ managed within residency programs, and under what conditions concerns are communicated to potential employers.

STUDY DESIGN

A web-based survey was emailed to 241 directors of US obstetrics and gynecology residency programs.

RESULTS

141 program directors (PDs) responded (58%). 84% of PDs indicated that problems with professionalism most commonly come to their attention through personal communication. Methods of addressing the problem included expression of expectation of improvement (95%), psychological counseling (68%), placing resident on probation (59%), and dismissal (30%). The majority of PDs felt remediation was not completely successful. All PDs are willing to communicate professionalism concerns to potential employers, but 42% provide this information only if asked.

CONCLUSION

Resident unprofessional behavior is a common problem for program directors, and remediation is challenging. PDs are willing to express concerns to potential employers, but a significant percentage indicate concerns only if asked.

Surgical resident peer evaluations-what have we learned

PURPOSE

Residents spend most of their time in the hospital with their respective junior and senior colleagues. Therefore, residents have a unique and valuable insight into their peers' professional qualities. Peer evaluation of values and virtues of each group may bring a different or an even better aspect of evaluating some ACGME core competencies. The purpose of this study was to identify the characteristics of junior and senior residents who are perceived to be role models in contrast to those who are not and to determine among these characteristics which is the most influential factor(s).

METHODS

Seventeen senior residents (4th and 5th) and 26 junior residents (1st, 2nd, and 3rd) evaluated each other in an anonymous manner 6 months apart on 3 separate occasions. Questionnaires for each group were designed by their evaluating group. Each questionnaire listed the qualities of a role-model resident anchored on a scale of 1-3.

RESULTS

A 1-way analysis of variance indicated that most of the time, the senior residents are perceived to be role models (the mean role-model rating = 2.87). A partial eta-squared analysis was performed to determine how well the specific performance factors differentiate the cases in which senior residents were perceived to be role models and when they were not. Clearly, professionalism along with attitude/expectations was the most differentiating factor. Similar statistical analyses were performed on seniors evaluating juniors. The role-model mean ratings were different significantly from one another (p = 0.014), which indicated that the senior residents varied significantly in the degree to which juniors were perceived to be role models.

CONCLUSION

In each group, both junior and senior residents value professionalism as the most important differentiating attribute of a role model. Seniors felt that knowledge was a less important attribute of a junior role model. Juniors felt teaching inside and outside of the operating room was a less important attribute of a senior role model.

Teaching and Assessing Professionalism in Ophthalmology Residency Training Programs

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency training programs teach and assess new competencies including professionalism. This article reviews the literature on medical professionalism, describes good practices gleaned from published works, and proposes an implementation matrix of specific tools for teaching and assessing professionalism in ophthalmology residency. Professionalism requirements have been defined by the ACGME, subspecialty organizations, and other certifying and credentialing organizations. Teaching, role modeling, and assessing the competency of professionalism are important tasks in managing the ACGME mandate. Future work should focus on the field testing of tools for validity, reliability, feasibility, and cost-effectiveness.

Patterns and Predictions of Resident Misbehavior—A 10-Year Retrospective Look

BACKGROUND

Surgical educators are charged with ensuring that their trainees conduct themselves in a professional manner. The authors retrospectively reviewed a 10-year experience of incident reports on surgical housestaff to determine patterns and predictors of behavior.

METHODS

A retrospective review of all letters, e-mails, and incident reports was conducted for general surgery residents from 1995 to 2005. Descriptive variables were selected for binary categorization (not mutually exclusive): poor professional conduct, protocol violation, administrative deficiency, verbal mistreatment, physical boundary issues, mistreatment of superiors, and deficient medical student interaction. Resident status was defined as current, graduate, and attrition.

RESULTS

Of 110 residents [90 [82%] categorical, 23 [21%] undesignated preliminary (3 overlapped both groups); 87 [79%] male, 23 [21%] female] who trained at the University of Pennsylvania during this period, 66 complaints were generated about 29 individuals. Overall, 50 of the 66 complaints (76%) were directed toward men and the remaining 16 (24%) toward women; 24% of all men and 35% of all women received 1 or more complaints. A total of 76% of complaints concerned categorical residents and 24% undesignated preliminary residents. And 26% of all categorical residents and 26% of all preliminary residents received at least 1 complaint. The most common complaints concerned professional conduct (83%), protocol violation (33%), verbal mistreatment (23%), deficiencies of administrative duties (8%), violations of physical boundaries (5%), deficient medical student interaction (5%), and mistreatment of attendings by residents (3%). Recipients of verbal mistreatment included staff nurses (27%), radiology technicians (13%), medical students (13%), environmental services employees (7%), security guards (7%), patients (7%), surgery attendings (7%), anesthesia attendings (7%), internal medicine chief residents (7%), and pharmacists (7%). A total of 31% of the complaints were regarding residents who involuntarily departed and 7% regarding residents who left voluntarily before completion. The mean PGY level at first complaint was 2.2 years. Of the 29 residents receiving complaints, 16 had recurrent offenses (range 2 to 7 total complaints, positive predictive value [PPV] 53%).

CONCLUSION

Resident misbehavior manifests early and recurs often. Furthermore, it is frequently directed toward perceived subordinates. Nondesignated preliminary status, premature departure from the program, and the eventual selection of specific subspecialty fellowships seems to increase the risk for resident misbehavior. Identified residents require close surveillance and remediation.

Medical student professionalism: are we measuring the right behaviors? A comparison of professional lapses by students and physicians

BACKGROUND

Examining the relationship between unprofessional behaviors observed in medical students and those manifested by physicians is important in determining whether medical school faculty are observing and reporting behaviors relevant to medical practice.

METHOD

This study compares the relationship between unprofessional behaviors identified in students at our medical school through Early Concern Notes, and behaviors for which physicians were sanctioned by our state medical board.

RESULTS

The majority of reports in both groups were related to lapses in professional responsibility and integrity, and the specific behaviors identified in the groups were similar. A smaller number of reports in both groups were related to pursuit of excellence or personal interactions.

CONCLUSION

There are common features to the professional shortcomings seen in students at our medical school and practicing physicians in our state. These similarities add credibility to our faculty's observations, and reinforce the relevance of monitoring such behaviors in future physicians.

The Professionalism Mini-evaluation Exercise: a preliminary investigation

BACKGROUND

As the evaluation of professional behaviors has been identified as an area for development, the Professionalism Mini-Evaluation Exercise (P-MEX) was developed using the mini-Clinical Examination Exercise (mini-CEX) format.

METHOD

From a set of 142 observable behaviors reflective of professionalism identified at a McGill workshop, 24 were converted into an evaluation instrument modeled on the mini-CEX. This instrument, designed for use in multiple settings, was tested on clinical clerks in medicine, surgery, obstetrics and gynecology, psychiatry, and pediatrics. In all, 211 forms were completed on 74 students by 47 evaluators.

RESULTS

Results indicate content and construct validity. Exploratory factor analysis yielded 4 factors: doctor-patient relationship skills, reflective skills, time management, and interprofessional relationship skills. A decision study showed confidence intervals sufficiently narrow for many measurement purposes with as few as 8 observations. Four items frequently marked below expectations may be identifiers for "problem" students.

CONCLUSION

This preliminary study suggests that the P-MEX is a feasible format for evaluating professionalism in clinical training.