The main utility of our educational exercise (the professionalism presentation) was to raise resident awareness regarding issues of doctor-patient communication and to expose them to a tool which has been used to survey patients about their perceptions of their doctors. Our psychometric analysis of the adaptation of the ABIM patient satisfaction survey for resident self-assessment shows highly acceptable levels of internal consistency reliability. In addition, factor analysis shows us the beginning development of two distinct components of professionalism ("interpersonal relations" and "conveying medical information"). These two components allow for the potential creation of separate sub-scales of professionalism. Of particular interest is the overlap on the two components of overall level of professionalism. This overlap could potentially be due to a number of influences. For instance, it could be that both subscales adequately measure overall professionalism and the item is important in both components. One might speculate that items related to "conveying information" are fairly mechanistic, whereas items related to "interpersonal relations" require being more in tune with the patient's emotions. Ginsburg and colleagues[37
] noted that the nature of professionalism is context-specific. Perhaps physicians need to rely on a different set of communication skills depending on the context of the clinical interaction (e.g., delivering a poor prognosis for a cancer versus describing the risks/benefits/alternatives of epidural anesthesia during labor). The issue of "sub-scales" of professionalism could be explored further by administering the survey to patients and residents immediately after a clinical encounter and noting the context of the interaction.
The results also show significant associations between self ratings and certain participant characteristics. Males tended to rate themselves higher than females on certain items. While this might be their self-perception, reality may prove contrary. In a study by Minter,[38
] female surgical residents were found to underestimate their skills compared to attending physician evaluation. Additional studies have found that females score better than males after a training course in communication skills, [39
] female physicians engage in more patient-centered communication than do males,[43
] and female graduates of medical schools outside the U.S. received slightly higher communication and interpersonal skills ratings than did male graduates of medical schools outside the U.S. on the United States Medical Licensing Examination™ Step 2 Clinical Skills exam.[44
] When the original ABIM survey was administered to patients for purposes of assessing physicians, female doctors received higher overall professionalism ratings from their patients.[19
Foreign graduates reported doing a better job at listening to their patients, whereas U.S. graduates reported using more understandable language. This may have more to do with confidence in English language proficiency rather than basic communication skills; foreign graduates might listen more closely so as not to misunderstand their patients, and their lack of confidence in speaking English might cause them to perceive that they are not speaking in language which is easily understandable to their patients. This would need to be pursued in a further study, particularly comparing resident self-assessment to actual patient perception.
Surgical residents rated themselves more positively in discussing options with patients compared to residents in non-surgical specialties. The quality of these communication skills has a substantial impact on patient outcomes, including superior recovery rates in patients undergoing surgical procedures,[45
] reduced need for analgesic use to treat post-operative pain,[46
] and improved emotional and functional adjustment in adult cancer patients.[47
] We might speculate that surgery residents' perceptions of their ability to discuss options might be higher than non-surgical residents' because, often in surgery, the options are more concrete (i.e., surgery versus no surgery) whereas patient management options in the non-surgical specialties are often less concrete (i.e., one medication regime versus another medication regime) and perhaps more difficult to articulate to patients.
Current schemes for evaluating communication skills and professionalism in students and residents have flaws when used in isolation.[37
] For instance, although standardized patients have been shown to be useful in evaluating the mechanics of clinical and communication skills,[48
] their reliability in assessing elements of professionalism is less established. These settings may also be considered contrived. Faculty evaluations of professional behavior using instruments with Likert scales have been shown to have poor reliability, primarily because the attending physician usually does not interact extensively with the student in the work environment. [49
] Peer evaluations, though they provide good information about interpersonal skills, are problematic because of the "halo effect" (i.e., if a person is popular, this "halo" may affect the evaluation of specific traits) and because peers are often reluctant to comment on poor behavior in colleagues.[1
] Actual patient evaluations would seem to be the best source of evaluation of communication skills, but can be influenced greatly by the setting in which they are performed.
Recent reviews of self-assessment in the health professions raise questions about the ability of professionals to generate accurate judgments of their own performance.[24
] Of even more concern is that those who perform the least well on external assessment may also overrate their performance on self-assessment exercises.[24
] Most studies of self-assessment are in areas of technical knowledge and ability.[24
] Even in concrete areas such as these, self-assessment has been found to be inaccurate.[29
] This may be of even more concern when the area of assessment is laden with value judgments, as is the case in communication skills and professionalism.[54
] In one study, medical residents perceived a high level of competence to discuss end-of-life issues, but failed to engage in recommended behaviors for such discussions.[55
] When surveys use self-assessment, they are subject to social desirability bias.[1
] This may limit the usefulness of these self-assessments to formative assessment and the formation of personal goals.[37
It is thought that a more representative picture of professional behavior can be obtained by surveying a variety of patients and people in the healthcare team because they interact with students and residents on a more regular basis and may provide a more informative picture of professional behavior throughout their academic career.[1
] This type of assessment is referred to as a "360-degree Evaluation." Resident self-assessment of professionalism skills may therefore be more useful when compared with the assessments made by others.[34
There may also be educational benefit simply by the process of self-reflection. Reflection, both on the process and content of learning can help students to monitor their own learning.[56
] Reflection-in-learning is related to readiness for self-regulation of learning and may be conducive to enhanced diagnostic ability.[58
] Studies have found that a greater effort of reflection is associated with a more positive or meaningful learning experience.[58
] The rationale for encouraging reflection in the promotion of self-directed learning is extensive.[60
] Actually, reflection is conceived as one of the metacognitive skills or cognitive regulation strategies required for the development of self-regulated learning, from a theoretical viewpoint.[61