Unprofessional conduct by resident colleagues and faculty conveys a hidden curriculum that contradicts professional standards and 5 undermine physician ideals. Consistent with prior studies,22,26
respondents reported frequently observing fellow residents engaging in unprofessional conduct. As residents are role models for interns and medical students,12
witnessing residents being disrespectful 5 dehumanize patients11
and perpetuate an unprofessional culture.28
We also found that residents and faculty were frequently observed criticizing other specialty services. This 5 be a pervasive characteristic of academic medical culture and 5 foster cynical attitudes.12
Finally, respondents felt humiliated frequently by nurses and patients, suggesting unprofessionalism has societal roots beyond physicians.
Previous studies suggest that cynicism is a prevalent feature of medical culture11,13,29,30
and 5 have significant consequences for physicians' behaviors and attitudes.31
Furthermore, cynicism 5 result in loss of empathy and decreased humanism,10
traits needed to form strong patient-physician relationships.31
Our findings suggest that cynicism 5 be socialized through the hidden curriculum.28
The 5-item tool we used to measure cynicism performed well, demonstrating expected strong correlation with depersonalization and internal consistency. This instrument requires further psychometric testing and validation to ensure that it measures the construct of cynicism and to confirm its relationship to burnout.
Residents who met burnout criteria witnessed significantly more unprofessional behavior overall than those who did not. These data suggest that an unprofessional learning environment is associated with resident distress. Previous studies18,27
have identified feelings of lack of control, loss of autonomy, and stressful work relationships as contributors to burnout. A recent study of medical students showed a correlation between burnout scores (MBI-EE and D) and poor professional climate scores,32
supporting our findings. The professionalism climate instrument functions much like our hidden curriculum measure, assessing observed behavior of faculty, residents, and students. The atmosphere created by unprofessional comments and cynical attitudes 5 impact residents' well-being, leading to increased detachment. Alternatively, residents who meet criteria for burnout 5 perceive their environment more negatively, creating a “toxic” learning environment. Lower empathy scores, a construct related to cynicism, also correlated with a poorer professional climate among medical students.32
This supports our results showing an association between unprofessional conduct and increased cynicism.
Cynicism and burnout were also highly associated, perhaps reflecting related constructs. In our operational definitions, we have attempted to differentiate these constructs, defining cynicism as a pessimistic view of medical care and burnout as a detached approach to patient care. However, this differentiation 5 be arbitrary. Rather than a coping response to the stresses of residency and protecting from burnout,33
cynicism 5 overlap with the construct of burnout and arise in response to similar job stresses and challenges.
This study has a number of limitations. First, the sample is drawn from only 2 academic institutions with a low response rate. Response bias 5 have significantly affected the results, with burnout likely affecting participation rates. Second, the hidden curriculum and cynicism instruments have not been validated and require additional testing. Professionalism, although extensively studied, is difficult to measure; there are few validated, reliable instruments.34
Our survey was developed and implemented before publication of the professionalism climate instrument, which appears to gather similar data about the learning environment in medical school.35
Our study establishes a similar promising instrument focusing on witnessed and experienced unprofessional conduct in residency. Further psychometric evaluation of our instrument and comparison with the professionalism climate instrument is necessary. Third, many of the survey items relied on recall of experiences during a prior year, which is subject to recall bias and 5 be influenced by resident well-being. The survey assesses 1 point in time; responses to burnout and cynicism questions likely vary, depending on residents' rotations and on other life stressors we did not explore. Finally, this cross-sectional analysis can only demonstrate associations, not causality.