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Effect of Balint training on resident professionalism
American Journal of Obstetrics and Gynecology (2006) 195, 1431–7
www.ajog.org
Effect of Balint training on resident professionalism Karen E. Adams, MD,* Meg O’Reilly, MD, Jillian Romm, LCSW, Kenneth James, PhD Department of Obstetrics and Gynecology, Oregon Health and Sciences University, Portland, OR Received for publication February 23, 2006; revised July 15, 2006; accepted July 31, 2006
KEY WORDS ACGME competencies Professionalism Balint Obstetrics and gynecology residents Medical education
Objective: The study was designed to assess the impact of 6 months of Balint training on self- and faculty-assessed measures of professionalism in obstetrics and gynecology residents. Study design: Pre- and post-Balint training resident self-assessment and pre- and post-training faculty assessment using standard professionalism instruments were used to compare the resident Balint group to the group that did not participate. Participating residents also completed a qualitative assessment of the experience. Results: Residents who participated were enthusiastic regarding the value of Balint in promoting self-reflection and gaining insight into self- and patient-care issues, both key components of professionalism. There were no significant differences in self or faculty assessment of professionalism between residents who participated in Balint and those who did not. Conclusion: Six months of Balint training was successful in providing resident education in professionalism, measured by resident self-report. No differences were detected on 2 measures of professionalism between the training and control groups. Ó 2006 Mosby, Inc. All rights reserved.
Graduate medical educators of all specialties are increasingly focused on creation and assessment of learning objectives, as well as the use of outcomes data, to facilitate continuous improvement of resident and residency program performance. The Accreditation Council for Graduate Medical Education (ACGME) emphasizes educational outcomes in residency education through its Outcome Project, in which programs are accredited based on their actual accomplishments in education rather than their potential to educate.1 Programs must provide educational experiences as needed in order for their residents to demonstrate appropriate * Reprint requests: Karen E. Adams, MD, Associate Professor and Residency Program Director, Department of Obstetrics and Gynecology, Mail code L-466, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2006.07.042
levels of competency in each of 6 specific areas: medical knowledge, patient care, systems-based practice, communication skills, practice-based learning and improvement, and professionalism. Educators are expected to utilize increasingly more useful, reliable, and valid methods of assessing residents’ attainment of learning objectives relating to these competencies.1,2 Instead of simply implementing a curricular element with the assumption that residents learned what was intended to be taught, as in the past, educators must now demonstrate that the desired learning was achieved. Methods suggested by the ACGME to teach professionalism include, among others, ‘‘discussions or seminars related to challenging psychosocial issues in patient care.’’ Improvement in professionalism should be assessed through ‘‘observation and recording, cognitive testing, and survey/rating instruments.’’3 Our study was designed to assess the impact of Balint training, a
1432 specific type of seminar related to challenging psychosocial issues in patient care, on the skills and attitudes important in resident professionalism through the use of both quantitative and qualitative assessment tools. Balint training, named after its founder, Michael Balint, MD, is a well-established part of many family medicine residencies both in the United States and abroad, and is included in some US training programs in other fields. Balint training consists of a small group of physicians who meet regularly to examine their own physician-patient relationships through the group members’ patient case presentations and trained faculty-facilitated discussions. This method of exploring the dynamics of their patient interactions, and of gaining insight into their own reactions to patients, may help physicians more effectively meet the biopsychosocial needs of their patients.4,5 In addition, Balint training has been proposed as a method to teach professionalism through improvement in listening skills with both patients and colleagues, encouraging integrative, creative, and divergent thinking, encouraging empathy, improving observation skills, and encouraging self-reflection and self-evaluation.6 Little research exists investigating the effectiveness of Balint training in improving residents’ professionalism, and much of the research that does exist involves practicing physicians rather than residents. An Israeli study that surveyed attitudes of residents post-graduation after having participated in Balint groups during residency training reported ‘‘that the course is generally a positive and valuable learning experience.(that) helped them acquire the skills to implement a patient-centered approach in their clinical work.’’7 This study did not utilize quantitative assessment tools. An Australian report proposed participation in Balint groups as a way to ‘‘prevent compassion fatigue and burnout in participants,’’ but did not gather specific data.8 Other authors have utilized quantitative assessments of Balint training with mixed results. One study was unable to demonstrate differences in empathy or work satisfaction between a group of South Carolina family medicine graduates who had undergone Balint training and those who had not, when surveyed using the Jefferson Scale of Physician Empathy and a validated survey on physician work satisfaction.9 A 10-point visual analogue scale was utilized to demonstrate positive effects of Balint training on practicing physicians’ sense of control of their work situation and positive attitudes related to caring for patients with psychosomatic problems in a 2004 Swedish study of general practitioners.10 Hematology/oncology fellows at the Cleveland Clinic showed improvement in ‘‘comfort dealing with emotional patient/clinical situations’’ via self-report by questionnaire following participation in a Balint-like physician awareness group.11 Turner and Malm utilized the Psychological Medicine Inventory (PMI) to show improvements in self-reported psychological medicine skills, abilities, and confidence in family medicine residents after
Adams et al 9 months of Balint training as compared to those who did not undergo Balint training.12 The obstetrics and gynecology residency program at Oregon Health and Sciences University (OHSU) has 2 faculty members who are trained Balint group facilitators. Given the importance of construction of learning objectives related to the competencies, development of specific curricular elements to teach each competency, and use of valid assessment tools to measure outcomes, the authors designed this study to implement an OBGYN Balint training program at OHSU and utilize several assessment tools to assess its effect on resident professionalism.
Material and methods This study was designed to compare outcomes on 2 measures of professionalism in 2 volunteer groups of residents when one group received 6 months of Balint training plus the standard residency curriculum, and one group received the standard residency curriculum only. Care was taken to choose assessment instruments that are considered appropriate to assess resident professionalism or have been shown to be affected by Balint training in previous studies.
Resident self-assessment All 24 obstetrics and gynecology residents at Oregon Health and Sciences University were invited to participate after an explanation of the research question, study design, and assessment measures were provided to them. The study protocol was reviewed and approved by the OHSU Institutional Review Board. Participation in the study did not affect residents’ rotation evaluations or other assessments already in place in the residency program. Resident self-assessments of interest, ability, or skill level in psychosocial aspects of patient care were obtained before Balint training and again after the training was completed using the Psychological Medicine Inventory (PMI), the validated self-rating instrument used in Turner and Malm’s study that showed a positive impact of Balint training.12 The items in the PMI cover the following themes: interest and confidence in dealing with the psychologic aspects of care, skill in developing good doctor-patient relationships, ability to recognize patients in distress, ability to obtain and interpret psychologic information from patients, ability to use mental health consultants, ability to make treatment decisions and be therapeutic based on patients’ psychologic needs, awareness of how patients react to them, and awareness of their own feelings, values, and needs.13
Faculty assessment Five faculty members of various subspecialties (generalist, perinatology, and urogynecology) provided pre- and
Adams et al post-Balint training evaluations of participating residents using the professionalism-related items on the Musick 360-degree evaluation instrument, one of the rating instruments recommended by the ACGME for assessment of resident professionalism. The Musick 360-degree evaluation was developed in a physical medicine and rehabilitation residency program, and was pilot-tested in the initial study with a group of 16 residents who were evaluated by faculty members, nurses, therapists, social workers, psychologists, and case managers.14 Since this instrument also includes items that do not relate to resident professionalism, our study utilized only the items in the survey designated by the ACGME as specifically related to professionalism.3 Faculty evaluators were recruited for the study by the primary author based on their frequent exposure to all the OBGYN residents in their role as full-time faculty members in a variety of clinical settings before, during, and after the 6 months of Balint training. Faculty were asked to evaluate all residents, were blinded to participation by the residents in the Balint meetings, and the evaluations for those residents not participating in the study were discarded.
Balint meetings The residency program director (KA) provided the study explanation and obtained informed consent, but was blinded to resident participation and randomization. The residency program coordinator performed the randomization and collection of both sets of confidential resident self-assessment data as well as faculty evaluations. Two other faculty members in the department who are credentialed Balint group leaders (MO, JR) led the groups but did not perform assessments of the residents. Balint meetings were held every other week from July through December 2005, and the content was confidential. At the conclusion of Balint training, participating residents completed a qualitative evaluation form regarding their experience in the group (Table I). Previous studies have demonstrated the limitations of quantitative measures to accurately assess changes in professionalism, and in anticipation of that, we opted to include a qualitative assessment component. A semistructured interview with each participant was considered, but it was felt by the authors that feedback regarding the experience of the Balint group would be more truthful if obtained through an anonymous questionnaire than in a face-to-face interview. This questionnaire was distributed by the Balint leaders at the close of the final session, and collected later that day by the residency coordinator.
Results The statistical analyses of both sets of data were straightforward, simply calculating the pre- and post-
1433 Table I
Participant evaluation of resident Balint group
1. Do you feel that Balint groups are useful for residents? Why or why not? 2. Was this group different from, or similar to, other small group experiences you’ve had? 3. What did you like best about the group, if anything? 4. What would you change, if anything? 5. What was the most valuable insight you gained from Balint? 6. What did you learn about the practice of medicine from Balint? 7. Any comments for the group leaders or the residency program director?
mean for each item on the PMI and the Musick-360 evaluation for each group, and comparing means between the Balint group and the control group.
Resident self-assessment A total of 16 residents volunteered for the study. Eight residents were randomized to the control and the Balint interventions, stratified by year of training, with randomization occurring within groups of volunteers in the same training year. Two residents, 1 each in the control and Balint interventions, did not sign the consent form, and there were no baseline (pre-Balint) data available for 1 control resident. All 3 of these residents were removed from the data analysis. Residents rated their level of interest, confidence, or ability in addressing the psychologic aspects of their patients’ problems from 1 (lowest) to 9 (highest). Table II shows the mean pre and post PMI scores for the 9 items and the total score for the sum of the items, as well as comparison between the control and the Balint group scores. None of the control versus Balint differences for any of the 9 items, or the total scores for the 2 groups, approached statistical significance.
Faculty assessment Each resident was scheduled to be evaluated by 5 OBGYN faculty members. The rating scale on various characteristics of professionalism ranged from 1 (unsatisfactory) to 9 (outstanding). For the 6 residents who received the control intervention there should have been 30 evaluations by faculty, and for the Balint intervention, with 7 residents assigned, there should have been 35 evaluations. However, not all faculty members rated each resident on each item, since not all faculty members had worked with every resident. Although faculty evaluators were chosen for their in-depth and consistent exposure to the residents, rotation schedules and the short time frame of the study meant that not every evaluator worked with every resident during the study period. Mean faculty evaluation scores were in the range of 6 to 8 points, with the post- and pre-differences ranging from ÿ0.13 to 0.93 for the 13 abilities (Tables III and
1434 Table II
Adams et al Mean total and item PMI scores for residents
Control* Pre Post Difference (SD) Balint* Pre Post Difference (SD)
Mean Total Score (SD)
Item 1 Interest
73.83 (9.24) 77.17 (12.86) 3.33 (4.84)
7.17 5.67 ÿ1.50 (2.07)
75.29 (12.84) 78.29 (9.18) 3.00 (15.14)
7.71 7.14 ÿ0.57 (21.5)
Comparison of post-pre difference for control versus Balint Difference (Control-Balint) 0.33 ÿ0.93 SD (Difference) 11.736 2.116 t 0.051 ÿ0.789 P value .96 .45
Item 3 MD/Pt relationships
Item 4 Recognition of distress
Item 5 Interview skills
6.83 6.83 0.00 (1.10)
7.83 7.83 0.00 (0.63)
7.17 7.67 0.50 (0.55)
5.67 6.83 1.16 (0.75)
6.71 6.57 ÿ0.14 (1.22)
7.14 7.00 ÿ0.14 (1.35)
7.57 7.86 0.29 (1.11)
6.29 6.71 0.42 (1.72)
0.21 0.899 0.428 .67
0.738 1.366 0.971 .35
Item 2 Confidence
0.14 1.163 0.221 .83
0.13 1.080 0.238 .82
* Control n = 6; Balint n = 7.
IV). The n column shows how many ratings each item received, and the total column reflects only the number of evaluations that were complete. However, none of the differences between the 2 groups were statistically significant. Table V is a comparison of the control group and the Balint group mean scores on each item, showing that the differences do not reach statistical significance in any item. The total professionalism score for the control group increased 7.69 points compared to 5.41 for the Balint group (P = .65). Interestingly, the Balint group professionalism pre-test scores were lower than the control group in almost every category. This may be explained by differences between the groups. The 2 groups were only matched as to year in training, but not by age, possible previous experience or professionalism training, gender, race/ethnicity, or other factors, because of the small numbers in each group.
Resident qualitative assessment Residents who were randomized to participation in the Balint group were asked to answer 7 questions regarding their experience (Table I). Every participant felt that Balint groups are useful for residents, with representative comments as follows: ‘‘Yes, Balint groups are very helpful for residents. It gives us the chance to really talk about our patients as human beings instead of specimens or textbook cases. In a Balint group you can try to figure out what makes taking care of one individual different from another person with the same medical condition. We are also able to identify what it is about ourselves that may be a challenge or a gift in terms of relating to certain patients.’’ ‘‘I think it is very valuable. You can share and process your own experiences and learn from others’ experiences to prepare for future patient encounters.’’
All participants felt that the group was different from previous small groups they had participated in because the Balint group became more intimate through personal sharing. Many of the participants commented on the intimacy they experienced in the group: ‘‘It is an explicit personal experience-sharing group, which makes it somewhat more intimate. You learn a lot about other people in a short time and it is necessary to trust each other.’’
There were multiple personal insights gained through participation in Balint reported by the participants: ‘‘You learn that there are multiple different ways of approaching a patient’s situation, even when you think there aren’t.’’ ‘‘That other people also continue to struggle with how much you can trust patients.’’ ‘‘How many issues there are around patient interactions.’’ ‘‘That I am not alone in my feelings toward my patients.’’ ‘‘Other residents struggle with some of the same problems I do.’’
Participants also felt that they learned valuable lessons about the practice of medicine from Balint: ‘‘So much of it has to do with patience and understanding instead of skill. I think this is something I believed early in med school but sort of lost touch with as the stress of residency has become more and more consuming.’’ ‘‘Being a doctor is part medicine, part emotional support.’’ ‘‘How important it is to continue to observe your relationship with patients in order to have a healthy relationship and stay healthy yourself.’’
Adams et al Table II
1435
(Continued)
Item 6 Ability to diagnose
Item 7 Ability to use consult
6.00 7.00 1.00 (0.63) 6.29 6.71 0.42 (1.40) 0.58 1.116 0.920 .38
Item 8 Ability to treat
Item 9 Therapeutic ability
6.83 7.00 0.17 (1.47)
6.17 7.00 0.83 (1.33)
5.33 6.17 0.84 (0.98)
7.00 7.33 0.33 (1.03)
7.83 7.83 0.00 (0.63)
6.57 7.71 1.14 (1.46)
6.43 7.00 0.57 (2.07)
6.43 6.86 0.43 (1.27)
6.86 7.29 0.43 (2.23)
7.29 7.43 0.14 (1.95)
0.26 1.770 0.266 .80
0.41 1.153 0.633 .54
ÿ0.97 1.467 ÿ1.196 .26
Item 10 Pt awareness
ÿ0.10 1.779 ÿ0.096 .93
Item 11 Self-awareness
ÿ0.14 1.503 ÿ0.171 .87
* Control n = 6; Balint n = 7.
Comment We were unable to demonstrate changes in professionalism self-assessment or faculty-assessment scores with the PMI or Musick 360-degree evaluation through Balint training, but residents who participated were enthusiastic about the value of Balint in promoting self-reflection and gaining insight into self and patient care issues, both key components of professionalism. Balint training was therefore successful in providing resident education in professionalism in this study as measured by resident qualitative self-report. Pre- and post-Balint assessments of resident professional behavior via rating scales, however, did not show a significant change over the 6-month intervention period. One of the major challenges in professionalism education is separating the effect of any curricular intervention designed to specifically teach professionalism from the effect of simply maturing as a resident: engaging in daily patient care, learning from senior resident and faculty role models, and participating in the usual learning curriculum. This project addressed that difficulty through the use of a control group of volunteers who were initially also interested in participation in Balint meetings but did not take part in the group. Although there may be significant differences between those who volunteered and those who did not, only volunteers were randomized, thus controlling for personality type or other factors that may lead a resident to be interested in such a project. Differences between the 2 groups were also minimized by stratification of randomization into training years, but as previously mentioned, many characteristics were not controlled for and may have accounted for the differences in pretest levels between the Balint and the control groups. The
small sample size was a significant limitation of this study, since residents could not be required to participate, and only 16 of 24 residents volunteered. Voluntary participation is a problem in conducting educational research, for if an intervention is shown to be beneficial, presumably it will be incorporated into curricula for all residents, not just volunteers. The effect may then be different when nonvoluntary participation is included, but such an effect is difficult to study because of the nature of informed consent in educational research. The short period of assessment is also a limitation of this study. It is possible that a longer period of time of Balint training may reveal an effect on resident professionalism that this 6-month study was unable to demonstrate. We remain convinced of the value of Balint training in residency programs as supported by our qualitative data. Other studies have demonstrated significant differences in professionalism between those who have participated in Balint groups and those who have not. Even with our ‘‘negative’’ quantitative results, important lessons can be drawn from this study. It highlights the critical nature of the assessment tool and the setting in which evaluation is obtained. Resident Balint training may also show benefit if assessed as a vehicle to teach the communication skills competency in addition to the professionalism competency. Most importantly, our study illustrates the difficulty of measuring small differences between residents who are already functioning at a high level of professionalism. As many educators recognize, the majority of residents are highly professional, and the rare resident who has difficulties in this area stands out acutely from his or her peers. Further research into professionalism may ultimately show that our educational goals in this area should be refined. We anticipate that graduate
1436 Table III
Adams et al Pre and post-rating of OB/GYN residents by OB/GYN faculty for control group Pre-intervention
Post-intervention
Difference
Item no.
Ability
n
Mean (SD)
Mean (SD)
Mean (SD)
1 2 3 4 5 6 7 8 9 10 11 12 13
Leadership skills Dependability/Responsibility Sensitivity/compassion Initiative Organizational skills Management skills Respect for others Self-confidence Promptness Receptivity to criticism Collaboration/goal setting Attendance at meetings Participation at meetings Total
22 22 24 24 23 22 24 24 21 22 19 19 19 16
7.41 7.64 7.58 7.29 7.26 7.05 7.54 7.25 7.71 7.18 7.47 7.79 7.74 98.00
7.59 7.82 7.54 7.83 7.83 7.68 8.04 7.63 8.43 7.68 8.11 8.32 8.32 105.69
0.18 0.18 ÿ0.04 0.54 0.57 0.63 0.50 0.38 0.72 0.50 0.64 0.53 0.58 7.69
Table IV
(1.10) (0.90) (0.97) (1.00) (1.29) (1.25) (0.98) (1.15) (0.96) (1.01) (1.07) (1.03) (1.10) (12.95)
(1.33) (1.22) (1.56) (1.27) (1.23) (1.32) (1.16) (1.47) (0.81) (1.59) (1.20) (0.89) (0.86) (14.64)
(1.18) (1.10) (1.37) (0.98) (1.04) (1.26) (1.18) (1.17) (1.06) (1.54) (1.34) (1.35) (1.35) (14.98)
Pre and post-rating of OB/GYN residents by OB/GYN faculty for Balint group Pre-intervention
Post-intervention
Difference
Item no.
Ability
n
Mean (SD)
Mean (SD)
Mean (SD)
1 2 3 4 5 6 7 8 9 10 11 12 13
Leadership skills Dependability/Responsibility Sensitivity/compassion Initiative Organizational skills Management skills Respect for others Self-confidence Promptness Receptivity to criticism Collaboration/goal setting Attendance at meetings Participation at meetings Total
22 24 24 23 21 21 24 24 18 22 14 18 18 12
5.77 6.63 6.58 6.17 6.24 6.14 6.75 6.42 7.11 7.05 6.21 7.50 7.22 89.17
5.64 7.21 7.00 6.83 6.91 6.62 7.08 6.50 8.00 6.96 7.14 8.11 7.83 94.58
ÿ0.13 0.58 0.42 0.66 0.67 0.48 0.33 0.08 0.89 ÿ0.09 0.93 0.61 0.61 5.41
Table V
(1.74) (1.28) (1.35) (1.50) (1.90) (1.88) (1.33) (1.61) (1.18) (1.36) (1.85) (0.77) (0.88) (13.51)
(1.79) (1.18) (1.75) (1.72) (1.61) (1.77) (1.84) (1.45) (0.77) (1.81) (1.41) (0.677) (0.68) (13.33)
(1.04) (1.28) (1.25) (1.11) (0.97) (1.17) (1.20) (1.25) (1.18) (1.438) (1.86) (0.98) (1.04) (9.35)
Comparison of Control - Balint Pre-Post Differences Control
Balint
Item no.
n
Mean (SD)
n
Mean (SD)
Difference
SD (Difference)
t
P value
1 2 3 4 5 6 7 8 9 10 11 12 13 Total
22 22 24 24 23 22 24 24 21 22 19 19 19
0.18 0.18 ÿ0.04 0.54 0.57 0.63 0.50 0.38 0.72 0.50 0.64 0.53 0.58 7.69
22 24 24 23 21 21 24 24 18 22 14 18 18 12
ÿ0.13 0.58 0.42 0.66 0.67 0.48 0.33 0.08 0.89 ÿ0.09 0.93 0.61 0.61 5.41
0.31 ÿ0.40 ÿ0.46 ÿ0.11 ÿ0.10 0.15 0.17 0.30 ÿ0.17 0.59 ÿ0.29 ÿ0.08 ÿ0.03 2.28
1.110 1.199 1.308 1.051 0.999 1.211 1.195 1.213 1.119 1.507 1.579 1.185 1.201 12.900
0.950 ÿ1.136 ÿ1.213 ÿ0.362 ÿ0.335 0.433 0.484 0.834 ÿ0.487 1.301 ÿ0.534 ÿ0.218 ÿ0.081 0.461
.35 .26 .23 .72 .74 .67 .63 .41 .63 .20 .60 .83 .94 .65
(1.18) (1.10) (1.37) (0.98) (1.04) (1.26) (1.18) (1.17) (1.06) (1.54) (1.34) (1.35) (1.35) (14.98)
(1.04) (1.28) (1.25) (1.11) (0.97) (1.17) (1.20) (1.25) (1.18) (1.438) (1.86) (0.98) (1.04) (9.35)
Adams et al medical educators may need to approach the professionalism competency, and possibly the communication skills competency, differently from the knowledge- and skill-based competencies. We may eventually abandon the goal of demonstrating improvement in professionalism in all our residents, which may prove to be a very difficult task. Perhaps we should ask a completely different question: how do we identify the rare resident who is unprofessional, and remediate that behavior? Such an important change in educational focus must be evidence-based. Continued research on methods designed to teach resident professionalism is critical for increased understanding of how adults learn and use highly sophisticated behaviors. A larger study to evaluate the effects of Balint training on residents in multiple residency programs in various geographic areas over a significantly increased period of time is planned, and will utilize communication skills assessments as well as professionalism assessments. This upcoming study will address the limitations of the current study, and will provide continued refinement of educational efforts in the area of resident professionalism.
Acknowledgments The authors wish to thank the residents who volunteered for the study and the faculty members who agreed to serve as evaluators. This manuscript was completed in partial fulfillment of the requirements for completion of the APGO/Solvay Educational Scholars Development Program. The authors would also like to thank department chair Joanna Cain, MD, for her guidance in preparation of this manuscript, as well as provision of financial support that allowed participation in the APGO/Solvay Program, all the Program faculty, and especially Program advisor Louis Vontver, MD, for
1437 provision of substantive guidance and advice in the preparation of this paper.
References 1. ACGME outcome project. Enhancing residency education through outcomes assessment. Chicago (IL): Accreditation Council for Graduate Medical Education; 2000. Available at: http://www. acgme.org/outcome/project. Accessed November 18, 2005. 2. Dauphinee WE, Blackmore DE. Assessing the assessor’s assessment. Med Educ 2001;35:317-8. 3. Advancing education in medical professionalism: an educational resource from the ACGME outcome project. Chicago (IL): Accreditation Council for Graduate Medical Education; 2004. Available at: http://www.acgme.org/outcome/implement/Profm_resource. pdf. Accessed November 18, 2005. 4. Zinn W. Doctors have feelings too. JAMA 1998;259:3296-8. 5. Glass RM. The physician-patient relationship: JAMA focuses on the center of medicine. JAMA 1996;275:147-8. 6. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. JAMA 1997;278:502-9. 7. Yeheskel A, Kiderman A, Borkan J, Herman J. A course for teaching patient-centered medicine to family medicine residents. Acad Med 2000;75:494-7. 8. Benson J, Magraith K. Compassion fatigue and burnout: the role of Balint groups. Aust Fam Phys 2005;34:497-8. 9. Cataldo K, Peeden K, Geesey M, Dickerson L. Association between Balint training and physician empathy and work satisfaction. Fam Med 2005;37:328-31. 10. Kjeldmand D, Holmstrom I, Rosenqvist U. Balint training makes GPs thrive better in their job. Patient Educ Couns 2004;55:230-5. 11. Sekeres M, Chernoff M, Lynch T, Kasendorf E, Lasser D, Greenberg D. The impact of a physician awareness group and the first year of training on hematology-oncology fellows. J Clin Oncol 2003;21:3676-82. 12. Turner A, Malm R. A preliminary investigation of Balint and nonBalint behavioral medicine training. Fam Med 2004;36:114-22. 13. Ireton HR, Sherman M. Self-ratings of graduating practice residents’ psychological medicine abilities. Fam Prac Res J 1988;7: 236-44. 14. Musick D, McDowell S, Clark N, Salcido R. Pilot study of a 360degree assessment instrument for physical medicine and rehabilitation residency programs. Am J Phys Med Rehabil 2003;82: 394-402.
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Effect of Balint training on resident professionalism Karen E. Adams, MD,* Meg O’Reilly, MD, Jillian Romm, LCSW, Kenneth James, PhD Department of Obstetrics and Gynecology, Oregon Health and Sciences University, Portland, OR Received for publication February 23, 2006; revised July 15, 2006; accepted July 31, 2006
KEY WORDS ACGME competencies Professionalism Balint Obstetrics and gynecology residents Medical education
Objective: The study was designed to assess the impact of 6 months of Balint training on self- and faculty-assessed measures of professionalism in obstetrics and gynecology residents. Study design: Pre- and post-Balint training resident self-assessment and pre- and post-training faculty assessment using standard professionalism instruments were used to compare the resident Balint group to the group that did not participate. Participating residents also completed a qualitative assessment of the experience. Results: Residents who participated were enthusiastic regarding the value of Balint in promoting self-reflection and gaining insight into self- and patient-care issues, both key components of professionalism. There were no significant differences in self or faculty assessment of professionalism between residents who participated in Balint and those who did not. Conclusion: Six months of Balint training was successful in providing resident education in professionalism, measured by resident self-report. No differences were detected on 2 measures of professionalism between the training and control groups. Ó 2006 Mosby, Inc. All rights reserved.
Graduate medical educators of all specialties are increasingly focused on creation and assessment of learning objectives, as well as the use of outcomes data, to facilitate continuous improvement of resident and residency program performance. The Accreditation Council for Graduate Medical Education (ACGME) emphasizes educational outcomes in residency education through its Outcome Project, in which programs are accredited based on their actual accomplishments in education rather than their potential to educate.1 Programs must provide educational experiences as needed in order for their residents to demonstrate appropriate * Reprint requests: Karen E. Adams, MD, Associate Professor and Residency Program Director, Department of Obstetrics and Gynecology, Mail code L-466, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2006.07.042
levels of competency in each of 6 specific areas: medical knowledge, patient care, systems-based practice, communication skills, practice-based learning and improvement, and professionalism. Educators are expected to utilize increasingly more useful, reliable, and valid methods of assessing residents’ attainment of learning objectives relating to these competencies.1,2 Instead of simply implementing a curricular element with the assumption that residents learned what was intended to be taught, as in the past, educators must now demonstrate that the desired learning was achieved. Methods suggested by the ACGME to teach professionalism include, among others, ‘‘discussions or seminars related to challenging psychosocial issues in patient care.’’ Improvement in professionalism should be assessed through ‘‘observation and recording, cognitive testing, and survey/rating instruments.’’3 Our study was designed to assess the impact of Balint training, a
1432 specific type of seminar related to challenging psychosocial issues in patient care, on the skills and attitudes important in resident professionalism through the use of both quantitative and qualitative assessment tools. Balint training, named after its founder, Michael Balint, MD, is a well-established part of many family medicine residencies both in the United States and abroad, and is included in some US training programs in other fields. Balint training consists of a small group of physicians who meet regularly to examine their own physician-patient relationships through the group members’ patient case presentations and trained faculty-facilitated discussions. This method of exploring the dynamics of their patient interactions, and of gaining insight into their own reactions to patients, may help physicians more effectively meet the biopsychosocial needs of their patients.4,5 In addition, Balint training has been proposed as a method to teach professionalism through improvement in listening skills with both patients and colleagues, encouraging integrative, creative, and divergent thinking, encouraging empathy, improving observation skills, and encouraging self-reflection and self-evaluation.6 Little research exists investigating the effectiveness of Balint training in improving residents’ professionalism, and much of the research that does exist involves practicing physicians rather than residents. An Israeli study that surveyed attitudes of residents post-graduation after having participated in Balint groups during residency training reported ‘‘that the course is generally a positive and valuable learning experience.(that) helped them acquire the skills to implement a patient-centered approach in their clinical work.’’7 This study did not utilize quantitative assessment tools. An Australian report proposed participation in Balint groups as a way to ‘‘prevent compassion fatigue and burnout in participants,’’ but did not gather specific data.8 Other authors have utilized quantitative assessments of Balint training with mixed results. One study was unable to demonstrate differences in empathy or work satisfaction between a group of South Carolina family medicine graduates who had undergone Balint training and those who had not, when surveyed using the Jefferson Scale of Physician Empathy and a validated survey on physician work satisfaction.9 A 10-point visual analogue scale was utilized to demonstrate positive effects of Balint training on practicing physicians’ sense of control of their work situation and positive attitudes related to caring for patients with psychosomatic problems in a 2004 Swedish study of general practitioners.10 Hematology/oncology fellows at the Cleveland Clinic showed improvement in ‘‘comfort dealing with emotional patient/clinical situations’’ via self-report by questionnaire following participation in a Balint-like physician awareness group.11 Turner and Malm utilized the Psychological Medicine Inventory (PMI) to show improvements in self-reported psychological medicine skills, abilities, and confidence in family medicine residents after
Adams et al 9 months of Balint training as compared to those who did not undergo Balint training.12 The obstetrics and gynecology residency program at Oregon Health and Sciences University (OHSU) has 2 faculty members who are trained Balint group facilitators. Given the importance of construction of learning objectives related to the competencies, development of specific curricular elements to teach each competency, and use of valid assessment tools to measure outcomes, the authors designed this study to implement an OBGYN Balint training program at OHSU and utilize several assessment tools to assess its effect on resident professionalism.
Material and methods This study was designed to compare outcomes on 2 measures of professionalism in 2 volunteer groups of residents when one group received 6 months of Balint training plus the standard residency curriculum, and one group received the standard residency curriculum only. Care was taken to choose assessment instruments that are considered appropriate to assess resident professionalism or have been shown to be affected by Balint training in previous studies.
Resident self-assessment All 24 obstetrics and gynecology residents at Oregon Health and Sciences University were invited to participate after an explanation of the research question, study design, and assessment measures were provided to them. The study protocol was reviewed and approved by the OHSU Institutional Review Board. Participation in the study did not affect residents’ rotation evaluations or other assessments already in place in the residency program. Resident self-assessments of interest, ability, or skill level in psychosocial aspects of patient care were obtained before Balint training and again after the training was completed using the Psychological Medicine Inventory (PMI), the validated self-rating instrument used in Turner and Malm’s study that showed a positive impact of Balint training.12 The items in the PMI cover the following themes: interest and confidence in dealing with the psychologic aspects of care, skill in developing good doctor-patient relationships, ability to recognize patients in distress, ability to obtain and interpret psychologic information from patients, ability to use mental health consultants, ability to make treatment decisions and be therapeutic based on patients’ psychologic needs, awareness of how patients react to them, and awareness of their own feelings, values, and needs.13
Faculty assessment Five faculty members of various subspecialties (generalist, perinatology, and urogynecology) provided pre- and
Adams et al post-Balint training evaluations of participating residents using the professionalism-related items on the Musick 360-degree evaluation instrument, one of the rating instruments recommended by the ACGME for assessment of resident professionalism. The Musick 360-degree evaluation was developed in a physical medicine and rehabilitation residency program, and was pilot-tested in the initial study with a group of 16 residents who were evaluated by faculty members, nurses, therapists, social workers, psychologists, and case managers.14 Since this instrument also includes items that do not relate to resident professionalism, our study utilized only the items in the survey designated by the ACGME as specifically related to professionalism.3 Faculty evaluators were recruited for the study by the primary author based on their frequent exposure to all the OBGYN residents in their role as full-time faculty members in a variety of clinical settings before, during, and after the 6 months of Balint training. Faculty were asked to evaluate all residents, were blinded to participation by the residents in the Balint meetings, and the evaluations for those residents not participating in the study were discarded.
Balint meetings The residency program director (KA) provided the study explanation and obtained informed consent, but was blinded to resident participation and randomization. The residency program coordinator performed the randomization and collection of both sets of confidential resident self-assessment data as well as faculty evaluations. Two other faculty members in the department who are credentialed Balint group leaders (MO, JR) led the groups but did not perform assessments of the residents. Balint meetings were held every other week from July through December 2005, and the content was confidential. At the conclusion of Balint training, participating residents completed a qualitative evaluation form regarding their experience in the group (Table I). Previous studies have demonstrated the limitations of quantitative measures to accurately assess changes in professionalism, and in anticipation of that, we opted to include a qualitative assessment component. A semistructured interview with each participant was considered, but it was felt by the authors that feedback regarding the experience of the Balint group would be more truthful if obtained through an anonymous questionnaire than in a face-to-face interview. This questionnaire was distributed by the Balint leaders at the close of the final session, and collected later that day by the residency coordinator.
Results The statistical analyses of both sets of data were straightforward, simply calculating the pre- and post-
1433 Table I
Participant evaluation of resident Balint group
1. Do you feel that Balint groups are useful for residents? Why or why not? 2. Was this group different from, or similar to, other small group experiences you’ve had? 3. What did you like best about the group, if anything? 4. What would you change, if anything? 5. What was the most valuable insight you gained from Balint? 6. What did you learn about the practice of medicine from Balint? 7. Any comments for the group leaders or the residency program director?
mean for each item on the PMI and the Musick-360 evaluation for each group, and comparing means between the Balint group and the control group.
Resident self-assessment A total of 16 residents volunteered for the study. Eight residents were randomized to the control and the Balint interventions, stratified by year of training, with randomization occurring within groups of volunteers in the same training year. Two residents, 1 each in the control and Balint interventions, did not sign the consent form, and there were no baseline (pre-Balint) data available for 1 control resident. All 3 of these residents were removed from the data analysis. Residents rated their level of interest, confidence, or ability in addressing the psychologic aspects of their patients’ problems from 1 (lowest) to 9 (highest). Table II shows the mean pre and post PMI scores for the 9 items and the total score for the sum of the items, as well as comparison between the control and the Balint group scores. None of the control versus Balint differences for any of the 9 items, or the total scores for the 2 groups, approached statistical significance.
Faculty assessment Each resident was scheduled to be evaluated by 5 OBGYN faculty members. The rating scale on various characteristics of professionalism ranged from 1 (unsatisfactory) to 9 (outstanding). For the 6 residents who received the control intervention there should have been 30 evaluations by faculty, and for the Balint intervention, with 7 residents assigned, there should have been 35 evaluations. However, not all faculty members rated each resident on each item, since not all faculty members had worked with every resident. Although faculty evaluators were chosen for their in-depth and consistent exposure to the residents, rotation schedules and the short time frame of the study meant that not every evaluator worked with every resident during the study period. Mean faculty evaluation scores were in the range of 6 to 8 points, with the post- and pre-differences ranging from ÿ0.13 to 0.93 for the 13 abilities (Tables III and
1434 Table II
Adams et al Mean total and item PMI scores for residents
Control* Pre Post Difference (SD) Balint* Pre Post Difference (SD)
Mean Total Score (SD)
Item 1 Interest
73.83 (9.24) 77.17 (12.86) 3.33 (4.84)
7.17 5.67 ÿ1.50 (2.07)
75.29 (12.84) 78.29 (9.18) 3.00 (15.14)
7.71 7.14 ÿ0.57 (21.5)
Comparison of post-pre difference for control versus Balint Difference (Control-Balint) 0.33 ÿ0.93 SD (Difference) 11.736 2.116 t 0.051 ÿ0.789 P value .96 .45
Item 3 MD/Pt relationships
Item 4 Recognition of distress
Item 5 Interview skills
6.83 6.83 0.00 (1.10)
7.83 7.83 0.00 (0.63)
7.17 7.67 0.50 (0.55)
5.67 6.83 1.16 (0.75)
6.71 6.57 ÿ0.14 (1.22)
7.14 7.00 ÿ0.14 (1.35)
7.57 7.86 0.29 (1.11)
6.29 6.71 0.42 (1.72)
0.21 0.899 0.428 .67
0.738 1.366 0.971 .35
Item 2 Confidence
0.14 1.163 0.221 .83
0.13 1.080 0.238 .82
* Control n = 6; Balint n = 7.
IV). The n column shows how many ratings each item received, and the total column reflects only the number of evaluations that were complete. However, none of the differences between the 2 groups were statistically significant. Table V is a comparison of the control group and the Balint group mean scores on each item, showing that the differences do not reach statistical significance in any item. The total professionalism score for the control group increased 7.69 points compared to 5.41 for the Balint group (P = .65). Interestingly, the Balint group professionalism pre-test scores were lower than the control group in almost every category. This may be explained by differences between the groups. The 2 groups were only matched as to year in training, but not by age, possible previous experience or professionalism training, gender, race/ethnicity, or other factors, because of the small numbers in each group.
Resident qualitative assessment Residents who were randomized to participation in the Balint group were asked to answer 7 questions regarding their experience (Table I). Every participant felt that Balint groups are useful for residents, with representative comments as follows: ‘‘Yes, Balint groups are very helpful for residents. It gives us the chance to really talk about our patients as human beings instead of specimens or textbook cases. In a Balint group you can try to figure out what makes taking care of one individual different from another person with the same medical condition. We are also able to identify what it is about ourselves that may be a challenge or a gift in terms of relating to certain patients.’’ ‘‘I think it is very valuable. You can share and process your own experiences and learn from others’ experiences to prepare for future patient encounters.’’
All participants felt that the group was different from previous small groups they had participated in because the Balint group became more intimate through personal sharing. Many of the participants commented on the intimacy they experienced in the group: ‘‘It is an explicit personal experience-sharing group, which makes it somewhat more intimate. You learn a lot about other people in a short time and it is necessary to trust each other.’’
There were multiple personal insights gained through participation in Balint reported by the participants: ‘‘You learn that there are multiple different ways of approaching a patient’s situation, even when you think there aren’t.’’ ‘‘That other people also continue to struggle with how much you can trust patients.’’ ‘‘How many issues there are around patient interactions.’’ ‘‘That I am not alone in my feelings toward my patients.’’ ‘‘Other residents struggle with some of the same problems I do.’’
Participants also felt that they learned valuable lessons about the practice of medicine from Balint: ‘‘So much of it has to do with patience and understanding instead of skill. I think this is something I believed early in med school but sort of lost touch with as the stress of residency has become more and more consuming.’’ ‘‘Being a doctor is part medicine, part emotional support.’’ ‘‘How important it is to continue to observe your relationship with patients in order to have a healthy relationship and stay healthy yourself.’’
Adams et al Table II
1435
(Continued)
Item 6 Ability to diagnose
Item 7 Ability to use consult
6.00 7.00 1.00 (0.63) 6.29 6.71 0.42 (1.40) 0.58 1.116 0.920 .38
Item 8 Ability to treat
Item 9 Therapeutic ability
6.83 7.00 0.17 (1.47)
6.17 7.00 0.83 (1.33)
5.33 6.17 0.84 (0.98)
7.00 7.33 0.33 (1.03)
7.83 7.83 0.00 (0.63)
6.57 7.71 1.14 (1.46)
6.43 7.00 0.57 (2.07)
6.43 6.86 0.43 (1.27)
6.86 7.29 0.43 (2.23)
7.29 7.43 0.14 (1.95)
0.26 1.770 0.266 .80
0.41 1.153 0.633 .54
ÿ0.97 1.467 ÿ1.196 .26
Item 10 Pt awareness
ÿ0.10 1.779 ÿ0.096 .93
Item 11 Self-awareness
ÿ0.14 1.503 ÿ0.171 .87
* Control n = 6; Balint n = 7.
Comment We were unable to demonstrate changes in professionalism self-assessment or faculty-assessment scores with the PMI or Musick 360-degree evaluation through Balint training, but residents who participated were enthusiastic about the value of Balint in promoting self-reflection and gaining insight into self and patient care issues, both key components of professionalism. Balint training was therefore successful in providing resident education in professionalism in this study as measured by resident qualitative self-report. Pre- and post-Balint assessments of resident professional behavior via rating scales, however, did not show a significant change over the 6-month intervention period. One of the major challenges in professionalism education is separating the effect of any curricular intervention designed to specifically teach professionalism from the effect of simply maturing as a resident: engaging in daily patient care, learning from senior resident and faculty role models, and participating in the usual learning curriculum. This project addressed that difficulty through the use of a control group of volunteers who were initially also interested in participation in Balint meetings but did not take part in the group. Although there may be significant differences between those who volunteered and those who did not, only volunteers were randomized, thus controlling for personality type or other factors that may lead a resident to be interested in such a project. Differences between the 2 groups were also minimized by stratification of randomization into training years, but as previously mentioned, many characteristics were not controlled for and may have accounted for the differences in pretest levels between the Balint and the control groups. The
small sample size was a significant limitation of this study, since residents could not be required to participate, and only 16 of 24 residents volunteered. Voluntary participation is a problem in conducting educational research, for if an intervention is shown to be beneficial, presumably it will be incorporated into curricula for all residents, not just volunteers. The effect may then be different when nonvoluntary participation is included, but such an effect is difficult to study because of the nature of informed consent in educational research. The short period of assessment is also a limitation of this study. It is possible that a longer period of time of Balint training may reveal an effect on resident professionalism that this 6-month study was unable to demonstrate. We remain convinced of the value of Balint training in residency programs as supported by our qualitative data. Other studies have demonstrated significant differences in professionalism between those who have participated in Balint groups and those who have not. Even with our ‘‘negative’’ quantitative results, important lessons can be drawn from this study. It highlights the critical nature of the assessment tool and the setting in which evaluation is obtained. Resident Balint training may also show benefit if assessed as a vehicle to teach the communication skills competency in addition to the professionalism competency. Most importantly, our study illustrates the difficulty of measuring small differences between residents who are already functioning at a high level of professionalism. As many educators recognize, the majority of residents are highly professional, and the rare resident who has difficulties in this area stands out acutely from his or her peers. Further research into professionalism may ultimately show that our educational goals in this area should be refined. We anticipate that graduate
1436 Table III
Adams et al Pre and post-rating of OB/GYN residents by OB/GYN faculty for control group Pre-intervention
Post-intervention
Difference
Item no.
Ability
n
Mean (SD)
Mean (SD)
Mean (SD)
1 2 3 4 5 6 7 8 9 10 11 12 13
Leadership skills Dependability/Responsibility Sensitivity/compassion Initiative Organizational skills Management skills Respect for others Self-confidence Promptness Receptivity to criticism Collaboration/goal setting Attendance at meetings Participation at meetings Total
22 22 24 24 23 22 24 24 21 22 19 19 19 16
7.41 7.64 7.58 7.29 7.26 7.05 7.54 7.25 7.71 7.18 7.47 7.79 7.74 98.00
7.59 7.82 7.54 7.83 7.83 7.68 8.04 7.63 8.43 7.68 8.11 8.32 8.32 105.69
0.18 0.18 ÿ0.04 0.54 0.57 0.63 0.50 0.38 0.72 0.50 0.64 0.53 0.58 7.69
Table IV
(1.10) (0.90) (0.97) (1.00) (1.29) (1.25) (0.98) (1.15) (0.96) (1.01) (1.07) (1.03) (1.10) (12.95)
(1.33) (1.22) (1.56) (1.27) (1.23) (1.32) (1.16) (1.47) (0.81) (1.59) (1.20) (0.89) (0.86) (14.64)
(1.18) (1.10) (1.37) (0.98) (1.04) (1.26) (1.18) (1.17) (1.06) (1.54) (1.34) (1.35) (1.35) (14.98)
Pre and post-rating of OB/GYN residents by OB/GYN faculty for Balint group Pre-intervention
Post-intervention
Difference
Item no.
Ability
n
Mean (SD)
Mean (SD)
Mean (SD)
1 2 3 4 5 6 7 8 9 10 11 12 13
Leadership skills Dependability/Responsibility Sensitivity/compassion Initiative Organizational skills Management skills Respect for others Self-confidence Promptness Receptivity to criticism Collaboration/goal setting Attendance at meetings Participation at meetings Total
22 24 24 23 21 21 24 24 18 22 14 18 18 12
5.77 6.63 6.58 6.17 6.24 6.14 6.75 6.42 7.11 7.05 6.21 7.50 7.22 89.17
5.64 7.21 7.00 6.83 6.91 6.62 7.08 6.50 8.00 6.96 7.14 8.11 7.83 94.58
ÿ0.13 0.58 0.42 0.66 0.67 0.48 0.33 0.08 0.89 ÿ0.09 0.93 0.61 0.61 5.41
Table V
(1.74) (1.28) (1.35) (1.50) (1.90) (1.88) (1.33) (1.61) (1.18) (1.36) (1.85) (0.77) (0.88) (13.51)
(1.79) (1.18) (1.75) (1.72) (1.61) (1.77) (1.84) (1.45) (0.77) (1.81) (1.41) (0.677) (0.68) (13.33)
(1.04) (1.28) (1.25) (1.11) (0.97) (1.17) (1.20) (1.25) (1.18) (1.438) (1.86) (0.98) (1.04) (9.35)
Comparison of Control - Balint Pre-Post Differences Control
Balint
Item no.
n
Mean (SD)
n
Mean (SD)
Difference
SD (Difference)
t
P value
1 2 3 4 5 6 7 8 9 10 11 12 13 Total
22 22 24 24 23 22 24 24 21 22 19 19 19
0.18 0.18 ÿ0.04 0.54 0.57 0.63 0.50 0.38 0.72 0.50 0.64 0.53 0.58 7.69
22 24 24 23 21 21 24 24 18 22 14 18 18 12
ÿ0.13 0.58 0.42 0.66 0.67 0.48 0.33 0.08 0.89 ÿ0.09 0.93 0.61 0.61 5.41
0.31 ÿ0.40 ÿ0.46 ÿ0.11 ÿ0.10 0.15 0.17 0.30 ÿ0.17 0.59 ÿ0.29 ÿ0.08 ÿ0.03 2.28
1.110 1.199 1.308 1.051 0.999 1.211 1.195 1.213 1.119 1.507 1.579 1.185 1.201 12.900
0.950 ÿ1.136 ÿ1.213 ÿ0.362 ÿ0.335 0.433 0.484 0.834 ÿ0.487 1.301 ÿ0.534 ÿ0.218 ÿ0.081 0.461
.35 .26 .23 .72 .74 .67 .63 .41 .63 .20 .60 .83 .94 .65
(1.18) (1.10) (1.37) (0.98) (1.04) (1.26) (1.18) (1.17) (1.06) (1.54) (1.34) (1.35) (1.35) (14.98)
(1.04) (1.28) (1.25) (1.11) (0.97) (1.17) (1.20) (1.25) (1.18) (1.438) (1.86) (0.98) (1.04) (9.35)
Adams et al medical educators may need to approach the professionalism competency, and possibly the communication skills competency, differently from the knowledge- and skill-based competencies. We may eventually abandon the goal of demonstrating improvement in professionalism in all our residents, which may prove to be a very difficult task. Perhaps we should ask a completely different question: how do we identify the rare resident who is unprofessional, and remediate that behavior? Such an important change in educational focus must be evidence-based. Continued research on methods designed to teach resident professionalism is critical for increased understanding of how adults learn and use highly sophisticated behaviors. A larger study to evaluate the effects of Balint training on residents in multiple residency programs in various geographic areas over a significantly increased period of time is planned, and will utilize communication skills assessments as well as professionalism assessments. This upcoming study will address the limitations of the current study, and will provide continued refinement of educational efforts in the area of resident professionalism.
Acknowledgments The authors wish to thank the residents who volunteered for the study and the faculty members who agreed to serve as evaluators. This manuscript was completed in partial fulfillment of the requirements for completion of the APGO/Solvay Educational Scholars Development Program. The authors would also like to thank department chair Joanna Cain, MD, for her guidance in preparation of this manuscript, as well as provision of financial support that allowed participation in the APGO/Solvay Program, all the Program faculty, and especially Program advisor Louis Vontver, MD, for
1437 provision of substantive guidance and advice in the preparation of this paper.
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