Implementation of Peer Review into a Physical Medicine and Rehabilitation Program and its Effect on Professionalism

Original Research

Implementation of Peer Review into a Physical Medicine and Rehabilitation Program and its Effect on Professionalism Jaclyn Bonder, MD, Douglas Elwood, MD, MBA, Jeffrey Heckman, DO, Austin Pantel, BS, Alex Moroz, MD Objective: To examine the effects of implementing a peer review evaluation system on residents’ attitudes and perceptions of professionalism, a core competency of the Accreditation Council for Graduate Medical Education (ACGME), in a Physical Medicine and Rehabilitation (PM&R) program. Design: Four classes of residents were divided prospectively into a control and an intervention group. All residents were asked to complete a survey regarding their attitudes and perceptions on both peer review and professionalism. Only 2 of these classes participated in a newly adopted peer review evaluation system, after which time all participants were again asked to fill out the surveys. Setting: Residents were from a PM&R residency program at an urban tertiary care medical center. Participants: All residents who completed the entire survey preintervention and postintervention were included. Methods: The intervention was the introduction of peer review into residents’ evaluation assessments. All residents filled out a survey with questions relating to peer review and professionalism before and after this intervention. Main Outcome Measurements: Outcomes include understanding how residents perceive various attributes of professionalism, peer review, and the interconnection of the 2. Results: Data analysis using SPSS was performed using survey scores for 46 residents preintrodution and postintroduction of a peer review evaluation system. Analysis revealed that residents who participated in the peer review process were more likely to agree that certain aspects of daily patient care, behaviors, and concepts were components of professionalism. However, they continued to believe that residents are ultimately not responsible for their colleagues’ professionalism and that peer review might be harmful to a residency program. Conclusion: This study introduces an interesting dichotomy. Peer review clearly influences resident outlook on professionalism and yet there is a high suspicion regarding its implementation. If appropriately implemented, peer review may be a potent method of enhancing the education of this ACGME requirement. PM R 2010;2:117-124

The Accreditation Council on Graduate Medical Education (ACGME) requires residency programs to adhere to 6 core competencies in training: patient care, systems-based practice, professionalism, practice-based learning, communication, and medical knowledge. These competencies were formed as part of the ACGME “Outcome Project” in response to a report issued by the Institute of Medicine in 2001 that called for major reform in the training of physicians and health professionals. By requiring program directors to show that residents had proficient performance in these 6 competencies, the ACGME shifted the focus of GME accreditation to educational outcomes [1,2]. Although most of these 6 competencies have been extensively studied, some are not as quantifiable and therefore not as carefully scrutinized. Professionalism is a subject that falls into the latter category. In this study, the PM&R

D.E. Department of Physical Medicine and Rehabilitation, New York University, New York, NY Disclosure: nothing to disclose J.H. Department of Physical Medicine and Rehabilitation, New York University, New York, NY Disclosure: nothing to disclose

INTRODUCTION

1934-1482/10/$36.00 Printed in U.S.A.

J.B. Department of Physical Medicine and Rehabilitation, New York University, 400 E. 34th Street, Suite 600, New York, NY 10016. Address correspondence to: J.B.; e-mail: [email protected] Disclosure: nothing to disclose

A.P. New York University School of Medicine, New York, NY Disclosure: nothing to disclose A.M. Department of Physical Medicine and Rehabilitation, New York University, New York, NY Disclosure: nothing to disclose Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org Submitted for publication July 31, 2009; accepted November 26.

© 2010 by the American Academy of Physical Medicine and Rehabilitation Vol. 2, 117-124, February 2010 DOI: 10.1016/j.pmrj.2009.11.013

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authors chose to examine professionalism in the context of peer review and how implementing a system of peer feedback may affect resident attitudes on the components of this competency. Historically, professionalism in medicine began to garner increasing attention in the early 1990s as researchers started addressing the idea that it was an important element of medical education, at both the undergraduate and graduate level. Concurrently, the American Board of Internal Medicine began “Project Professionalism.” As part of this initiative, the American Board of Internal Medicine defined the elements of professionalism as: altruism, accountability, excellence, duty, honor, and integrity and respect for others [2]. The ACGME describes professionalism more broadly, stating that it is a “commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population” [1]. The movement to examine this competency more closely to further define and understand how it continues to accelerate. Accordingly, over the last decade, it has been examined in various contexts with regard to how it should be taught and what characteristics constitute an accurate depiction of its true nature [3-8]. Ultimately, unlike most of the other core competencies, professionalism remains somewhat ambiguous because it is an amalgamation of attitude, approach, interaction, communication, and other traits. Research suggests that implementing educational activities to foster professionalism among residents is a difficult endeavor and that evaluating this competency is challenging for program directors across disciplines [8-11]. Some specialties have attempted to accomplish this task by incorporating different strategies, such as holding retreats wherein residents were forced to work in teams or establishing a separate curriculum concentrating solely on professionalism [10]. Other approaches such as mentoring and role modeling have also been proposed as powerful tools to promote professionalism [6,7,12,13]. Originally popularized in the business sector as part of 360° evaluation, peer review has since been adopted by the medical profession [10,14]. Using peer review as a method of professional regulation has indeed been suggested as an effective means of assessing professionalism and reinforcing professional behavior among colleagues in medicine [15,16] and within Physical Medicine and Rehabilitation (PM&R) [17]. It has also been suggested that its implementation is an important source of comprehensive assessment [18] and may be a powerful tool in changing behaviors [11,13,19]. Additionally, it has been suggested that peer review may be superior to reviews by faculty [18]. Finally, peer review has been suggested as a valuable way of providing feedback in residency programs [15-17]. Because physicians are in the unique position of facing multiple audiences including patients, colleagues, nurses, and others, each with their own idea of what professionalism entails [5], understanding how peer review affects residents’

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professional competency may assist in the process of effectively training residents in this area [5,19]. The authors therefore chose to examine the effect on professionalism of the implementation of a peer review evaluation system in a PM&R residency program.

METHODS Nearly 50 residents from a PM&R program at an urban tertiary care medical center participated in this study and were prospectively divided into 2 groups. The intervention group (n ⫽ 24) took part in a newly adopted peer review evaluation system designed for house staff; the control group (n ⫽ 22) did not participate in the peer review process. The peer evaluation consisted of rating coresidents on a 9-point scale in 5 different categories including: practice-based learning and improvement, interpersonal and communication skills, professional attitudes, humanistic qualities, and overall clinical competence. Residents in both groups filled out a self-administered survey exploring attitudes on peer review and professionalism. All 4 groups of residents completed this task before the introduction of peer review. Four months later, after the peer review process had been used for 2 full cycles of evaluations, all 4 groups again filled out the surveys. Peer review had not been part of previous resident evaluations. To facilitate anonymity, many different factors were considered. First, there are no rotations with fewer than 3 residents (all rotations last 2 months). Second, a particular resident’s identification is revealed only to the program director after submitting feedback, not to any other resident, and results are not released to an individual resident until 5 reviews have been recorded. Finally, the program director meets with residents biannually to discuss the feedback and does not mention individual residents’ names associated with comments. The survey instrument, composed of a 9-point scale with questions relating to attitude and perception, was divided into 2 sections: one on professionalism and one on peer review. For professionalism, topics were incorporated within the framework of professional behavior, such as being prompt and accepting responsibility. For peer review, questions centered more on resident attitudes and how this system might affect the program or individual behaviors. Statistical analysis was completed with SPSS version 13.0. To explore potential relationships between control and intervention groups, pre and posttest means were collected and compared via t-test. A statistical level of .05 was selected for all calculations. Results are presented in both gross mean scores and in change in means (referred to henceforth as “delta mean” or DM), which was calculated by subtracting the pretest and posttest mean score for each question for both groups.

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Table 1. Delta Analysis with Professionalism: Non Significant Results Control

I am familiar with the ACGME definition of professionalism Faculty are responsible for ensuring residents are professional Residents are responsible for ensuring other residents act professionally Protecting patient confidentiality is a facet of professionalism Strict discipline is a key component of implementing professionalism

Intervention

PRE

POST

SD

PRE

POST

SD

DM

P Value

4.98 7.93 2.10

5.23 8.09 2.76

0.72 1.10 0.80

5.47 7.97 1.99

5.97 7.02 2.84

1.01 1.02 0.77

0.25 0.79 0.19

.17 .43 .28

7.87 2.87

8.05 2.58

1.23 0.93

7.67 3.12

7.59 3.98

0.87 0.78

0.10 0.66

.45 .08

PRE ⫽ before implementation of peer review; POST ⫽ after implementation of peer review; SD ⫽ standard deviation; DM ⫽ delta mean; ACGME ⫽ Accreditation Council for Graduate Medical Education.

RESULTS Of the 50 residents who were asked to fill out surveys, 46 completed them. There were 22 residents in the control group and 24 residents in the intervention group. The project started in May to take advantage of the transition to a new academic year. At that time, incoming residents (those about to begin postgraduate year 2) were contacted to fill out the survey and subsequently were identified as the control group along with graduating residents. The intervention group consisted of the remaining 2 classes of residents. To present the results in detail, the authors divided the results into 4 sections. The first section pertains to the overall impression of professionalism and the second examines residents’ impressions of peer review. The authors further divided both of these categories into questions with means that did not show statistically significant change and those that did. Tables 1-4 list each question from the survey with respective data based on the design of the questionnaire.

Section 1: Professionalism Table 1 depicts the questions that did not show statistically significant change with regard to professionalism. Both intervention and control group residents answered that faculty are primarily responsible for ensuring professionalism among

residents (DM ⫽ 0.79, P ⫽ .43), not other residents (DM ⫽ 0.19, P ⫽ .28). Whether or not residents were involved in the peer review process, participants agreed that patient confidentiality is a facet of professionalism (DM ⫽ 0.10, P ⫽ 0.45), whereas strict discipline was not viewed as an integral component of implementing professionalism (DM ⫽ 0.66, P ⫽ .08). Also, participants who completed the peer review evaluation process believed they were more familiar with the ACGME definition of professionalism after the 2 cycles, but this change was not statistically significant (DM ⫽ 0.25, P ⫽ .17). Several questions pertaining to professionalism showed statistically significant change with the introduction of peer review (Table 2). Residents in the intervention group, for example, answered more positively that professionalism should be a core competency (DM ⫽ 1.74, P ⫽ .04) and that it should be taught during training (DM ⫽ 2.52, P ⬍ .01) after participating in the peer review process. These same residents also gave statistically significant higher scores to the questions that arriving promptly (DM ⫽ 2.46, P ⬍ .001), accepting responsibility (DM ⫽ 3.53, P ⬍ .01), and dressing and acting appropriately (DM ⫽ 2.50, P ⬍ .01) are all components of professionalism. Residents who evaluated their peers also answered higher in regard to the idea that teamwork is an essential component of professionalism com-

Table 2. Delta Analysis with Professionalism: Significant Results Control

Professionalism should be one of the 6 core competencies of the ACGME Professionalism should be taught in residency training Arriving promptly to work is a facet of professionalism Accepting responsibility is a facet of professionalism Dressing and acting appropriately are facets of professionalism Professional behavior by residents influences patient outcomes Professional behavior by residents influences patient satisfaction Strong leadership is a key component of implementing professionalism Teamwork is a key component of professionalism

Intervention

PRE

POST

SD

PRE

POST

SD

DM

P Value

5.80

6.03

0.64

6.23

8.20

1.13

1.74

.04

4.34 4.01 4.20 4.13 2.93 2.07 2.96

4.76 4.08 4.02 3.96 2.76 1.94 2.91

0.93 1.02 0.68 0.98 0.78 0.92 0.79

4.57 4.27 3.97 4.38 3.04 2.28 3.02

7.50 6.79 7.58 7.05 6.03 5.99 8.39

0.88 1.03 1.08 0.93 0.78 0.93 0.99

2.52 2.46 3.53 2.50 2.82 3.58 5.32

⬍.01 ⬍.001 ⬍.01 ⬍.01 ⬍.01 ⬍.01 ⬍.001

2.08

2.33

0.68

2.28

7.30

1.10

4.76

⬍.001

PRE ⫽ before implementation of peer review; POST ⫽ after implementation of peer review; SD ⫽ standard deviation; DM ⫽ delta mean; ACGME ⫽ Accreditation Council for Graduate Medical Education.

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Table 3. Delta Analysis with Peer Review: Non Significant Results Control

Peer review affects resident interaction Resident evaluation of other residents is as important as faculty evaluations Peer review can be misused and therefore can be detrimental Other staff (eg, nurses, therapists) should evaluate resident performance Attendings should also have peer review to evaluate each other My peer reviews will be important components of resident evaluation

Intervention

PRE

POST

SD

PRE

POST

SD

DM

P Value

7.46 2.19

7.31 2.35

0.86 0.69

7.59 2.42

7.94 2.52

1.02 0.48

0.10 0.06

.18 .27

8.20 2.22

8.01 2.27

0.98 1.02

7.98 2.48

8.96 3.84

0.27 1.36

0.81 1.31

.21 .07

6.84 3.74

7.20 3.43

0.49 0.98

6.53 4.12

6.04 4.39

0.64 0.45

0.13 0.04

.38 .29

PRE ⫽ before implementation of peer review; POST ⫽ after implementation of peer review; SD ⫽ standard deviation; DM ⫽ delta mean.

pared with those who did not (DM ⫽ 4.76, P ⬍ .001). Additionally, this intervention significantly increased residents’ belief that professional behavior might affect patient satisfaction (DM ⫽ 3.58, P ⬍ .01) and outcomes (DM ⫽ 2.82, P ⬍ .01). Finally, strong leadership (such as by attendings, program directors, and chairs) was viewed as a key component of implementing professionalism more by those who participated in peer review (DM ⫽ 5.32, P ⬍ .001).

Section 2: Peer Review The results of the survey concerning peer review were also evaluated. Table 3 provides the questions that did not reveal statistically significant change with implementation of this evaluation system. For instance, those in the control and intervention groups agreed that peer review would affect how residents interact towards each other (DM ⫽ 0.10, P ⫽ .18). Also, residents answered that they did not think resident evaluation is as important as evaluation by faculty (DM ⫽ 0.06, P ⫽ .27) or that evaluation of residents by other staff members (eg, nurses, therapists) should be an important component of resident evaluations (DM ⫽ 1.31, P ⫽ .07). All of the residents had high mean scores regarding the concern that peer review could be misused and may be detrimental to a residency program (DM ⫽ 0.81, P ⫽ .21). Table 4 lists the questions from the peer review portion of the survey that did reveal statistically significant change in scores. Members of the intervention group had a statistically

significant increase in their answers regarding whether or not residents should be able to evaluate each others’ performance (DM ⫽ 3.96, P ⬍ .001). Similarly, these residents also thought that peer review would strengthen the program (DM ⫽ 3.92, P ⬍ .01), encourage teamwork (DM ⫽ 4.01, P ⬍ .001), and enhance professionalism (DM ⫽ 4.09, P ⬍ .0001) after evaluating their colleagues. Residents who were involved in the peer review process also answered more positively about the idea that peer feedback is relevant to their performance (DM ⫽ 1.96, P ⫽ .02) and believed that they were qualified to provide feedback on their peers (DM ⫽ 0.98, P ⫽ .05).

DISCUSSION The ACGME core competencies have been examined in a variety of ways. One of these competencies, professionalism, has attracted more attention recently as a push in the medical field toward compassionate physicians gains momentum. The United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills test is an example of this shift, because residents are expected to act professionally toward patients in order to pass the examination. The idea of professionalism has been emphasized in medicine for many decades and extends well beyond medical ethics [6]. This study explored this subject in a novel manner by using the specific intervention of peer review and examining its effect on resident appreciation and outlook of this topic.

Table 4. Delta Analysis with Peer Review: Significant Results Control

Residents should be able to evaluate each others’ performance Peer review will strengthen our program Peer review encourages teamwork Peer review enhances professionalism I support peer review in residency Peer feedback is relevant to my performance I am qualified to provide feedback on my peers

Intervention

PRE

POST

SD

PRE

POST

SD

DM

P Value

4.17

4.32

0.37

4.62

8.73

1.26

3.96

⬍.001

3.80 2.97 1.93 2.16 3.89 5.03

3.79 3.12 2.22 2.51 3.28 5.28

1.01 0.77 1.17 1.03 1.24 0.58

3.68 4.28 2.38 2.31 3.62 5.52

7.61 8.44 6.76 6.57 6.29 6.75

1.89 2.01 1.85 1.39 2.08 0.96

3.92 4.01 4.09 3.91 1.96 0.98

⬍.01 ⬍.001 ⬍.0001 ⬍.001 ⫽.02 ⫽.05

PRE ⫽ before implementation of peer review; POST ⫽ after implementation of peer review; SD ⫽ standard deviation; DM ⫽ delta mean.

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Figure 3. Professionalism effects. *A statistically significant change pre and postintervention was noted.

Figure 1. Facets of professionalism. *A statistically significant change pre and postintervention was noted.

Results are surprising in some cases. Simply by forcing residents to evaluate each other, attitudes shifted to placing more emphasis on professional behavior and being more cognizant of how important interactions are among residents and with patients. For instance, as depicted in Figure 1, when asked about key components of professionalism, those that had assessed one another increased their agreement that accepting responsibility, arriving promptly, and dressing and acting appropriately are aspects of professionalism. On the other hand, from the moment one enters medical school, the idea of patient confidentiality is taught, encouraged, and enforced in all aspects of health care. Therefore, it is not surprising that all residents confirmed that protecting patient confidentiality is a facet of professionalism. Those residents who participated in peer review also supported the use of a peer review evaluation system as part of their overall assessment and that associated feedback would be relevant to their performance. They answered that such a system might strengthen the residency program, encourage teamwork, and enhance professionalism (Figure 2). These findings may be utilized to enhance the way residents interact with the many different populations in a hospital (patients, colleagues, fac-

Figure 2. Peer review effects. *A statistically significant change pre and postintervention was noted.

ulty, nursing, etc) by using the peer review framework as a method of refining other qualities that constitute professionalism such as respect and accountability. These results also suggest that merely by implementing this type of evaluation process into a PM&R residency program simple professional behaviors may be reinforced perhaps by forcing residents to consider their actions and how they may be perceived. Building on this idea may help residency programs produce residents who exhibit and apply skills that are needed to be successful in those characteristics that comprise professionalism and create a more collaborative atmosphere. Given the interdisciplinary nature of PM&R, this concept is especially pertinent. There has also been research focusing on physician behavior and effects on patient satisfaction and outcomes [20,21]. It is interesting that participants in the peer review group became more attuned to how their behavior may influence these 2 subjects (Figure 3). Any intervention in residency training that bolsters this connection is valuable since residents are in fact on the front lines of medical care. Not all results were positive, however. Residents in both the control and intervention groups consistently answered that it is ultimately not their responsibility to ensure that their colleagues are maintaining professional behavior and that this role should be exclusively that of attending physicians. Similarly, neither group saw resident evaluation of other residents as an integral component of evaluation, which is surprising based on the support they had for it in other questions. These findings establish a potent dichotomy: that although residents feel that feedback from their peers is helpful in some realms, they simultaneously think it is unnecessary and unimportant in their development as physicians. Furthermore, both control and intervention residents remain concerned that the peer review process could be misused and therefore detrimental. Figure 4 highlights this contradiction. This disparity uncovers the unique nature of professionalism in medical education and introduces important questions as to the utility of peer review in the future. If program directors consider using peer feedback as a means of addi-

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Figure 4. Opinions on peer review. *A statistically significant change pre and postintervention was noted.

tional evaluation for residents, they perhaps need to ensure that residents feel safe to express their opinions anonymously. Also, safeguards need to be in place to prevent residents from using it to voice personal grievances, and they need to be clearly demarcated so there is no misunderstanding. In this study, every effort was made to ensure that residents understood this policy, but the inherent conflict apparently persisted. Another issue raised here is how best to implement professionalism with peer review. Figure 5 depicts 2 possible methods: either through strict discipline or strong leadership. Residents clearly indicate that they would prefer the latter, though that does not mean they would respond to it more effectively. Though this study has limitations, it is to the authors’ knowledge the first to examine the implementation of peer review and its direct effect on resident attitudes toward professionalism. It would be worthwhile to explore this concept in more detail by expanding this intervention to multiple specialties and by using a larger sample size. An informational bias may have developed in this study because of a lack of concrete definitions of question stems. Perhaps more detailed education on the meaning of professionalism and background data on its importance would be helpful. In addition, design requirements hampered randomization. Because intervention implementation revolved around the start of a new educational year, the incoming and outgoing groups were

Figure 5. Components of implementing professionalism. *A statistically significant change pre and postintervention was noted.

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Figure 6. Opinions on professionalism. *A statistically significant change pre and postintervention was noted.

necessarily placed in the control group. Also, there were no questions that tested knowledge of the actual definition of professionalism, only its elements. In addition, more information regarding individual resident rotations and combinations of residents on them might have brought to light further confounding variables to interpretation of results. Another limitation stems from an inability to compare individual residents’ pretest and posttest responses because surveys were administered anonymously. The authors therefore cannot comment on the degree to which each participant changed his or her feelings. Similarly, results for the control group may be skewed given its composition of ingoing and outgoing residents because postgraduate year 2 might have weighed down average scores because of less training on the subject. Examining this topic over a longer period or with more concrete control of resident understanding of how the evaluations will be used would benefit understanding of this intervention. Despite these limitations, peer review may be an invaluable method of enhancing professionalism education. The results of this study suggest that, although implementation of a peer review process may have an effect on residents’ professional standards and that residents support professionalism as one of the 6 core competencies, they remain uncomfortable with the ACGME definition of professionalism (Figure 6). This result may explain why those who participated in peer review felt that professionalism should be taught in residency training. It also establishes the idea that the first step for programs may be to clearly define what professionalism includes. Initial resident orientations could address such definitions not only for this core competency, but also for the others. Residents should then repeat training on the core competencies during subsequent years. Residents also may benefit from participation in case-based workshops to demonstrate professional behavior and reiterate important points. Because instructions on core competencies are becoming more prevalent, integrating defined concepts of professionalism into curricula would highlight its multidimensional nature. A pedagogic approach would facilitate this process and could draw on the professional standards of the residency program and medical center.

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It would be interesting to incorporate other methods of formal teaching that could be used to teach residents about professionalism and then compare their effectiveness. Given recent emphasis on the connection of patient satisfaction and outcomes, it would be beneficial to explore this idea as well since results of this study suggest a potential connection. Additionally, addressing expectations and development of specific professional skills that are essential to PM&R, such as teamwork and establishing rapport with nonphysicians, might be useful for resident professional performance. Teambuilding and leadership training activities would aid in this process. Finally, it is clear that the manner in which peer review and professionalism programs are implemented is important with regards to program leadership. Therefore, discussing results of reviews and traits of professionalism with department faculty is critical to its success. Another study supports this notion by demonstrating that behaviors can change simply with training lectures [4]. Given the idea that attendings can influence resident professionalism, grand rounds as well as other ongoing efforts to keep faculty abreast of ACGME core competencies and to maintain proper conduct become important as well. Expanding peer review evaluations to include a comprehensive assessment from other staff may alter resident attitudes to an even greater extent [14,17]. The ACGME clearly, and rightfully, demarcates professionalism as an essential element of resident training. Although there are many potential interventions to improve knowledge and performance of this core competency, this study suggests that peer review implementation has the potential to alter resident perception of many facets of professionalism and should therefore be considered in any future designs investigating this topic.

REFERENCES 1. Accreditation Council for Graduate Medical Education, Outcome Project. February 1999. Available at online: http://www.acgme.org. Accessed August 16, 2008. 2. Blackall, GF, Melnick SA, Shoop, GH, et al. Professionalism in medical education: The development and validation of a survey instrument to assess attitudes toward professionalism. Med Teacher 2007;29:e58-e62.

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3. Surdyk PM, Lynch DC, Leach, DC. Professionalism: Identifying current themes. Curr Opin Anesthesiol 2003;16:597-602. 4. Joyner B, Vemulakonda VM. Improving professionalism: Making the implicit more explicit. J Urol 2007;177:2287-2291. 5. West CP, Huntington JL, Huschka MM, et al. A prospective study of the relationship between medical knowledge and professionalism among internal medicine residents. Acad Med 2007;82:587-592. 6. Arnold L. Assessing professional behavior: Yesterday, today, and tomorrow. Acad Med 2002;77:516-522. 7. Fries M. Professionalism in obstetrics-gynecology residency education: the view of program directors. Obstet Gynecol 2000;95:314-316. 8. DeLisa JA, Foye PM, Jain SS, Kirshblum S, Christodoulou C. Measuring professionalism in a physiatry training program. Am J Phys Med Rehabil 2001;80:225-229. 9. Mustovic E, Miknevich MA, Fletcher C. An innovative method for teaching professionalism in a PM&R residency. Am J Phys Med Rehabil 2005;84:203. 10. Dorotta I, Staszak J, Takla A, Tetzlaff J. Teaching and evaluating professionalism for anesthesiology residents. J Clin Anesth 2006;18: 148-160. 11. Rodgers KG, Manifold C. 360-degree feedback: Possibilities for assessment of the ACGME core competencies for emergency medicine residents. Acad Emerg Med 2002;9:1300-1304. 12. Maker VK, Donnelly MB. Surgical resident peer evaluations – What have we learned. J Surg Educ 2008;65:8-16. 13. Gray JD. Global rating scales in residency education. Acad Med 1996; 71:S55-S62. 14. Haurani MJ, Rubinfeld I, Rao S, et al. Are the communication and professionalism competencies the new critical values in a resident’s global evaluation process? J Surg Educ 2007;64:351-356. 15. Thomas PA, Gebo KA, Hellmann DB. A pilot study of peer review in residency training. J Gen Intern Med 1999;14:551-554. 16. Ramsey PG, Wenrich MD. Peer ratings: An assessment tool whose time has come. J Gen Intern Med 1999;14:581-582. 17. Musick DW, McDowell SM, Clark N, Salcido R. Pilot study of a 360-deg assessment instrument for physical medicine and rehabilitation residency programs. Am J Phys Med Rehabil 2003;82:394402. 18. Arnold L, Shue CL, Kalishman S, et al. Can there be a single system for peer assessment of professionalism among medical students? A multiinstitutional study. Acad Med 2007;82:578-586. 19. Tintinalli JE. Evaluation of emergency medicine residents by nurses. Acad Med 1989;64:49-50. 20. DiMatteo MR. Predicting patient satisfaction from physicians’ nonverbal communication skills. Med Care 1980;18:376-387. 21. Cornstock LM. Physician behaviors that correlate with patient satisfaction. Acad Med 1982;57:105-112.

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APPENDIX 1. SURVEY INSTRUMENT Postgraduate Year Level

Circle 1-9

Male/Female

1 ⴝ Strongly Disagree

Section One

9 ⴝ Strongly Agree

Section 1 I am familiar with the ACGME definition of professionalism Professionalism should be one of the 6 core competencies of the ACGME Faculty are responsible for ensuring residents are professional Residents are responsible for ensuring other residents act professionally Professionalism should be taught in residency training Arriving promptly to work is a facet of professionalism Accepting responsibility is a facet of professionalism Dressing and acting appropriately are facets of professionalism Protecting patient confidentiality is a facet of professionalism Professional behavior by residents influences patient outcomes Professional behavior by residents influences patient satisfaction Strict discipline is a key component of professionalism Strong leadership is a key component of professionalism Teamwork is a key component of professionalism

1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5

6 6 6 6 6 6 6 6 6 6 6 6 6 6

7 7 7 7 7 7 7 7 7 7 7 7 7 7

8 8 8 8 8 8 8 8 8 8 8 8 8 8

9 9 9 9 9 9 9 9 9 9 9 9 9 9

Section 2 Residents should be able to evaluate each others’ performance Peer review affects resident interaction Peer review will strengthen our program Resident evaluation of other residents is as important as faculty evaluations Peer review can be misused and therefore can be detrimental Other staff (eg, nurses, therapists) should evaluate resident performance Peer review encourages teamwork Peer review enhances professionalism I support peer review in residency Peer feedback is relevant to my performance I am qualified to provide feedback on my peers Attendings should also have peer review to evaluate each other My peer reviews will be important components of resident evaluation

1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5

6 6 6 6 6 6 6 6 6 6 6 6 6

7 7 7 7 7 7 7 7 7 7 7 7 7

8 8 8 8 8 8 8 8 8 8 8 8 8

9 9 9 9 9 9 9 9 9 9 9 9 9

ACGME ⫽ Accreditation Council for Graduate Medical Education.