Sometimes you can't make it on your own: the impact of a professionalism curriculum on the attitudes, knowledge, and behaviors of an academic plastic surgery practice.

INTRODUCTION: Professionalism is now recognized as a core competency for graduate medical education and maintenance of certification. However, few models exist in plastic surgery that define, teach, and assess professionalism as a competency. The purpose of this project was to evaluate the effectiveness of a professionalism curriculum in an academic plastic surgery practice. METHODS: We created and conducted a 6-wk, 12-h course for health care professionals in plastic surgery (faculty, residents, nurses, medical students). Teaching methods included didactic lectures, journal club, small group discussions, and book review. Topics included: (1) Professionalism in Our Culture, (2) Leadership Styles, (3) Modeling Professional Behavior, (4) Leading Your Team, (5) Managing Oneself, and (6) Leading While You Work. Using Kirkpatrick methodology to assess perception of the course (level 1 data), learning of the material (level 2 data), effect on behavior (level 3 data), and impact on the organization (level 4 data), we compiled participant questionnaires, scores from pre- and post-tests, and such metrics as incidence of sentinel events (defined as infractions requiring involvement by senior administrators), number of patient complaints reported to Patient Relations, and patient satisfaction (Press Ganey surveys), for the 6 mo before and after the course. RESULTS: Thirty health care professionals participated in a 6-wk course, designed to improve professionalism in plastic surgery. Level 1 data: Although only 56.5% of respondents felt that the course was a "good use of my time," 73.9% agreed that the course "will help me become a better professional" and 82.6% "would recommend the course to others." Level 2 data: Post-test scores increased from 48% to 70% (P < 0.05), and the ability to recall all six competencies increased from 22% to 73% (P < 0.01). Level 3 data: The number of sentinel events in our division decreased from 13 to three. After the course, one resident was placed on probation and resigned, and two other employees left the division after being counseled on issues of professionalism. Interestingly, these participants did very well on the post-test but were not considered to be "team players." Level 4 data: Patient complaints decreased from 14 to eight, and patient satisfaction increased from 85.5% to 90.5%. CONCLUSIONS: A focused curriculum in professionalism may improve the knowledge of participants and overall behavior of the group, but may not affect individual attitudes. Nevertheless, efforts toward assessing, teaching, and influencing professionalism in plastic surgery are very valuable and should be pursued by educators to help satisfy Graduate Medical Education/Maintenance of Certification requirements and to improve the performance of the organization.

Have predictors of obstetrics and gynecology career choice among contemporary US medical graduates changed over time?

OBJECTIVE: We sought to identify predictors of obstetrics and gynecology (OBGYN) specialty choice among US medical graduates over time. STUDY DESIGN: We examined OBGYN specialty choice for its association with 16 items on the 1997, 2000, and 2004 AAMC Graduation Questionnaire (GQ). Multivariate logistic regression identified independent predictors of OBGYN specialty choice for each year. RESULTS: Eighty-three percent of US graduates completed the GQ in the 3 years studied. Fewer responders chose OBGYN over time (1997, 8.2%; 2000, 6.5%; 2004, 6.2%). Women, blacks, and graduates with more positive ratings of the OBGYN clerkship were more likely to choose OBGYN in each year (each P < .001). Graduates reporting more positive beliefs about the practice of medicine and preferring academic careers were less likely to choose OBGYN (each P < .05). CONCLUSION: Predictors of OBGYN specialty choice from among the GQ variables tested have remained stable over time, but with a smaller pool of likely applicants.

Protocol Standards for Reporting Video Data in Academic Journals.

Editors of biomedical journals have estimated that a majority (40%-90%) of studies published in scientific journals cannot be replicated, even though an inherent principle of publication is that others should be able to replicate and build on published claims. Each journal sets its own protocols for establishing "quality" in articles, yet over the past 50 years, few journals in any field--especially medical education--have specified protocols for reporting the use of video data in research. The authors found that technical and industry-driven aspects of video recording, as well as a lack of standardization and reporting requirements by research journals, have led to major limitations in the ability to assess or reproduce video data used in research. Specific variables in the videotaping process (e.g., camera angle), which can be changed or be modified, affect the quality of recorded data, leading to major reporting errors and, in turn, unreliable conclusions. As more data are now in the form of digital videos, the historical lack of reporting standards makes it increasingly difficult to accurately replicate medical educational studies. Reproducibility is especially important as the medical education community considers setting national high-stakes standards in medicine and surgery based on video data. The authors of this Perspective provide basic protocol standards for investigators and journals using video data in research publications so as to allow for reproducibility.

Verbal Aggressiveness Among Physicians and Trainees.

OBJECTIVE: To better understand verbal aggressiveness among physicians and trainees, including specialty-specific differences. DESIGN AND PARTICIPANTS: The Infante Verbal Aggressiveness Scale (IVAS) was administered as part of a survey to 48 medical students, 24 residents, and 257 attending physicians. The 72 trainees received the IVAS and demographic questions, whereas the attending physicians received additional questions regarding type of practice, career satisfaction, litigation, and personality type. RESULTS: The IVAS scores showed high reliability (Cronbach α = 0.83). Among all trainees, 56% were female with mean age 28 years, whereas among attending physicians, 63% were male with mean age 50 years. Average scores of trainees were higher than attending physicians with corresponding averages of 1.88 and 1.68, respectively. Among trainees, higher IVAS scores were significantly associated with male sex, non-US birthplace, choice of surgery, and a history of bullying. Among attending physicians, higher IVAS scores were significantly associated with male sex, younger age, self-reported low-quality of patient-physician relationships, and low enjoyment talking to patients. General surgery and general internal medicine physicians were significantly associated with higher IVAS scores than other specialties. General practitioners (surgeons and medical physicians) had higher IVAS scores than the specialists in their corresponding fields. No significant correlation was found between IVAS scores and threats of legal action against attending physicians, or most personality traits. Additional findings regarding bullying in medical school, physician-patient interactions, and having a method to deal with inappropriate behavior at work were observed. CONCLUSIONS: Individuals choosing general specialties display more aggressive verbal communication styles, general surgeons displaying the highest. The IVAS scoring system may identify subgroups of physicians with overly aggressive (problematic) communication skills and may provide a backdrop for educating physician communicators. The relationship between verbal aggressiveness and efficacy of clinical communication merits inquiry.

Clerkship enhancement of interpersonal skills.

BACKGROUND: The purpose of this research was to determine if students improve interpersonal skills as the third year progresses despite the lack of any specific curriculum or teaching methods. METHODS: Third-year students completed 1 of 3 16-week sequential clerkship blocks. Each student completed a clinical performance examination before and after clerkship consisting of a videotaped standardized patient interview and physical examination. Videotapes were randomly assigned to communication faculty for evaluation. RESULTS: Although the majority (73%) of students improved during their block, 17% showed no improvement, and 12% had deficient interpersonal skills after their clerkship. CONCLUSIONS: Despite the lack of skill-directed curriculum, most medical students showed improved interpersonal skill performance after a 16-week clerkship. Developing an interpersonal curriculum for all third-year students may not be necessary. Because faculty are being asked to do more with less, we believe efforts focused on individual students during the third year will be more productive.

The remedial year in the general surgery board certification process: how effective is it?

BACKGROUND: The American Board of Surgery (ABS) intends to assure high standards for knowledge and experience in every graduate from an approved general surgery program. They have gone to great lengths to devise an optimal remediation process for every candidate failing to reach these standards. But what is the effectiveness of the remediation process? METHODS: ABS data outlined the history and development of the remediation process up to its current form. A core component of this process is a specifically structured additional year of training at selected institutions. Ten institutions, which were classified as outstanding by the ABS, received a standardized confidential questionnaire to collect data that included the institution's impetus to administer a remedial year (RY), organization of their RY, specific emphasis points, role of advisors, funding, and choice of RY candidates. Each institution was asked to mail a letter to their RY graduates, asking for their participation in a follow-up study aimed at characterizing the failing candidate. RESULTS: ABS data have been available since 1980. Pass rates for the qualifying written examination (QE) improved steadily from about 63% in 1985 to 78% in 2003. Pass rates for the certifying oral examination (CE) have been consistently around 75% since 1985 with improvement to just above 80% within the last 4 years. In 1995, a new ABS policy was announced requiring an additional year of structured training with specific elements. For the QE, the general pool pass rates continued their steady improvement. Although the results for RY candidates did reveal a 20% improved pass rate, they were still 30 percentage points lower when compared with the general pass rates. No improvement was noted in the CE results. In 2003, ABS enacted the latest policy change, which consists of an alternative pathway for QE. The initial experience for 2003 is disappointing. Less than 10 candidates have taken advantage of this alternative, and pass rates have not improved. The policy for CE was changed to allow 5 attempts (up from 3 attempts) in 5 years, and currently it is too early to determine the impact of this change. Nine of 10 institutions agreed to participate in our study. They identified the essential elements of a successful RY. They also emphasized that CE remediation has to go beyond correction of simple knowledge deficits. And they characterized the ideal candidate for remediation. No RY graduates agreed to participate in the planned follow-up study to characterize the failing candidate. CONCLUSION: The RY process seems to have a valid potential if specific conditions are met. We do believe that differentiation is needed between the QE and the CE remedial year programs. Because the CE incorporates rhetorical skills, an emphasis should be placed on public speaking and presentation skills in a remedial year for the CE. We recommend several possible avenues for consideration: identifying the resident at risk and intervening during residency, incorporating the RY process into the ongoing practice routine of the individual candidate, and actively recruiting participation of candidates in a needs assessment study.

Factors affecting the professional image of physicians.

OBJECTIVE: The purpose of this study was to use an experimental design to determine the effect of selected aspects of dress on the professional image of physicians in an adult outpatient setting by those who use the health care services the most (55+), the least (18 to 22), and other physicians on whom we depend for referrals. METHODS: Ten slides of physicians representing a variety of ages; ethnic and religious affiliations were shown to 3 populations across the United States and Canada. Set 1 (N = 216) was shown to undergraduates and rated on 10 attributes of professional image. Two slides were altered and retested in a rotated order (Set 2). Set 1 was then tested with groups of elderly and surgeons (N = 277). RESULTS: Significant differences were found between Set 1 and Set 2 for the altered physician slides. There was high correlation of professionalism with the identified attributes for all 3 rater populations. The nonverbal attributes chosen for this study did accurately assess "professionalism." Gender of the rater or physician did not have any effect. Although the most "professional" surgeon was the oldest in the study, the second most "professional" was the youngest. CONCLUSIONS: It is clear that a surgeon's image is a mirror of competence, trust, expertise, and compassion. The variables described in this study may easily be implemented to reflect a more positive professional image with our peers and patients than simply adding a white coat. No one goes to see a surgeon to establish a casual relationship, and because it is difficult to counteract initial impressions, attention to these variables is important.

The certifying examination of the american board of surgery: the effect of improving communication and professional competency: twenty-year results.

PURPOSE: In 1985, a small research group identified variables affecting applicant success on the oral Certifying Examination (CE) of the American Board of Surgery (ABS). This led to the design of an oral examination course first taught in 1991. The success of and need for this program led to its continuation. The results from the first 10 years were presented at the 2001 Association of Program Directors in Surgery annual meeting.(1) We now report the outcomes for the course of the second 10 years as measured by success on the CE. METHODS: Thirty-six courses were held over 20 years. There were 57 invited faculty from 27 general surgery programs throughout the United States and Canada. The participant-to-faculty ratio ranged from 16:7 to 5:1 in the newer 3-day format (2007). Courses were offered at sites that replicated the actual examination setting. Each course included (1) pretest and posttest examinations, (2) analysis of case presentation skills, (3) measurement of communication apprehension, (4) 1:1 faculty feedback, (5) small-group practice sessions, (6) individual videotaping, (7) didactic review of specific behaviors on examinations, (8) a debrief session with two faculty members, and (9) a written evaluative summary that included an improvement strategy. RESULTS: There were 36 courses with 326 participants (30-54 years). Follow-up data are available for 225 participants. Trends were analyzed between 1991-2001 and 2002-2011. As resident performance on the CE increased in importance, applicant profiles changed from those who had previously failed (1991-2001) to residents identified by program directors as needing assistance (52%). Since 2002, most course participants (69%) who had failed the CE had completed at least 1 other review course. Participants reported more significant stressors (2002-2011) 9%, but communication apprehension remained the same. As a result, individual counseling for anger and family stressors was integrated into the course. The perception of knowledge deficits was associated with those who enrolled in fellowship training and delayed their examination. The recent groups exhibited more professionalism and articulation issues related to performance. Five surgeons (2002-2011) were asked not to return to the course because of severe knowledge deficiencies or ethical/behavioral issues based on faculty evaluations. Although complete follow-up of all participants was not possible (only 225/326), the success rate among those providing follow-up was 97% for those who followed their remediation plan, giving 218/326, a worse-case pass rate of 67%. CONCLUSION: Communication and professionalism deficits are still common in those struggling with the CE, Early identification of those at risk of failing by program directors who are documenting the competencies may promote earlier interventions and thus lead to success. This program continues to be effective at identifying behaviors that interfere with success on the CE of the ABS.

Is it live or is it Memorex? Student oral examinations and the use of video for additional scoring.

BACKGROUND: Oral examination interrater consistency has been questioned, supporting the use of at least paired examiners and consensus grading. The scheduling flexibility of video recording allows more examiners to score performances. The purpose of this study was to compare live performance with video performance scores to assess interrater differences and the effect on grading. METHODS: A total of 283 consecutive, structured, videotaped 30-minute examinations were reviewed. A 5-point Likert scale ranked problem solving (2 cases), verbal skills, and nonverbal skills. Nonparametric paired analyses tested for differences. RESULTS: Live performance scores were higher for verbal and nonverbal skills and total scores. Video performance scores were higher for problem solving for the first presented case. The largest difference (.29 Likert point) was in nonverbal skills. CONCLUSIONS: The minor yet statistical differences in several scores did not actually impact student grades. The use of video recording is sufficiently reliable to be continued and advocated.