The clinical performance of physicians has come under increasing scrutiny as greater public attention is paid to the quality of health care.1 In the past few years, national accreditation and governmental agencies have begun using process and quality of care benchmarks (such as community-acquired pneumonia treatment and angiotensin-converting enzyme inhibitor usage) as part of accreditation and reimbursement schemas.2,3 As a result, residency programs, where physicians are taught how to practice medicine, have also come under closer scrutiny.4 Medical educators, with guidance from the Accreditation Council for Graduate Medical Education (ACGME),5 are trying to improve the performance of future practicing physicians. However, basic questions still remain unanswered. How do educators and administrators understand the key factors affecting physician performance? How do we define and measure physician performance? What effect do the factors of individual physician (e.g., learning style, job stress, medical debt, personality traits) have on performance?
Focusing on residents, we attempted to answer these questions by conceptualizing factors affecting an individual physician's performance, and by conducting a systematic review on a subset of those factors. We developed a theoretical model of individual performance that conceptualizes the interactions among the individual practitioner, the system of care in which he or she practices, and the models of education used to teach residents. Performance has been defined by Webster's as “the execution of an action,”6 We defined an individual physician's performance as the actions undertaken during the process of patient care. These actions themselves are influenced by an individual physician's knowledge, skills, attitudes, and habits. If the knowledge, skills, attitudes, and habits comport with professional standards, the physician may be observed to be performing competently.7 From the perspective of patient care, a physician who treats congestive heart failure must understand the pathophysiology of cardiomyopathy and available treatment options (knowledge). The physician must use that knowledge to treat the patient and communicate effectively (skills), and believe that the patient and the condition are worthy of treatment (attitudes). They must also practice what they know on a regular basis (habits). From a physician's perspective, these practice outcomes may be influenced by numerous variables such as a physician's job satisfaction, quality of life, personality traits, learning styles, and personal physical health.
We chose residents as our study population because training programs are beginning to assess many areas of physician performance, due to increased review of physician competencies by accreditation bodies.4 Presumably, the increased scrutiny about performance will have beneficial effects on patient care as residents transition to independent practice. Residents also may be in a more standardized educational and health system environment than are practicing physicians, who may have greater practice variation. Thus, several areas that we hypothesize would affect performance may be more fixed among residents than in the pool of practicing physicians.
Model of resident performance
We used an expert consensus panel to develop a focused theoretical model of factors that contribute to an individual resident's performance. In 2002–03, seven educators (a vice dean for medical education; three program directors in medicine, pediatrics, and psychiatry; a medical education researcher; a health services researcher; and a medicine chief resident) brainstormed in a series of 15 separate meetings over eight months to generate major themes for our model. During those meetings, we also considered information from sources such as the Physician's Worklife Study,8 comments from the Institute of Medicine's Crossing the Quality Chasm,9 and books on educational theory and learning styles.10–13 We then identified major areas that we hypothesized would affect resident performance, and the relationships between those variables. For the purpose of this review, we call these hypothesized variables “performance-related factors.”
We developed our model using the standard health services Medical Outcomes Model approach of “input ⇒ process ⇒ output.”14 For residents' personal factors, we defined input as the resident's inner state influenced by both the medical education and health system infrastructures. We defined process as the immediate performance of the resident regarding patient care, and output as the effect of that performance on the patients, the health care system and the population (see Figure 1). We postulated that physicians' inner states are affected by the learning that results from feedback about performance process/outcomes, which forms a feedback loop to the individual resident. The model underwent eight rounds of review. From the model, we generated key words for a focused literature review.
The purpose of our systematic review was to illuminate areas of the model and test its construction against literature on resident performance. The educational literature is replete with information on the effects of curricular changes, feedback, and evaluation on a learner's demonstrated performance.15–18 However, most studies did not examine the influence of the variables of individual physicians on resident performance, in the context of other educational variables. Additionally, health system variables, such as payment plans, resources, and hospital staffing, have not been studies with an eye toward their influence on the factors of individual physicians or on resident performance. Thus, we focused on a subset of the performance model: the resident's inner state as it relates to patient care measures.
Using PubMed, we conducted a search for articles published between 1967–2002 using the key terms “residency” or “resident,” and key terms related to outcomes of physician performance and to variables of individual physicians: “coping,” “cynicism,” “attitudes,” “empathy,” “altruism,” “distress,” “stress,” “personality,” “motivation,” “learning style,” “self-learning,” “health,” “career goals,” “debt,” “expectations,” “burnout,” “emotions,” “knowledge,” “service,” “satisfaction,” and “performance.”
Approximately 1,100 titles were retrieved and reviewed for original research data on resident performance. We excluded commentaries, letters, keynote addresses, consensus documents, policy papers without original data, reviews, studies from non-Western countries, and non-English-language papers. Fifty-two articles contained original data relevant to resident performance and included both cross-sectional and longitudinal studies. Each article was reviewed for the method of obtaining data, the response rate, predictor and outcome variables (where relevant), and significant findings. The final articles were also examined for themes or hypotheses about physician performance to generate variables for a model on resident performance.
We identified five major categories of personal factors that comprise the inner state of the physician: learning style and personality, practice preferences, personal health, social/financial factors, and response to job environment. For each of the five categories, in Table 1 we have summarized the study design, study population, significant results, and have indicated whether the study outcomes were associated with measures of physician performance. No studies established causal relationships between variables.
Learning style and personality
Using the search terms “motivation,” “learning style,” “self-learning,” “expectations,” and “career goals,” we found no pertinent articles.
We found five studies that looked at residents' personalities. Four of these studies looked at the relationship between personality and performance. None of these four studies used the same methods of evaluation, making direct comparison difficult. Girard's longitudinal study of internal medicine residents found that 48% of the variation in clinical ranks and 38% of the variation on American Board of Internal Medicine (ABIM) examinations could be explained by psychological states and personality characteristics.19 Reich et al.20 examined cognitive, personality, and academic measures related to clinical performance in anesthesia residents. They found that poor clinical performance was associated with difficulty in performing tasks that require divided attention such as complex visual target detection. Personality traits associated with poor performance were introversion and flexibility (flexibility is defined as liking variety and change, and being easily bored). Lacorte and Risucci21 found that pediatrics residents who were younger and more extroverted scored higher on both clinical evaluations and exams. Pasnau and Bayley22 followed 27 first-year psychiatry residents and found that their personality patterns did not change throughout a given year.
We found no studies that examined a resident's preferences for practice in relationship to his or her individual performance. This was not unexpected, because despite their personal preferences, residents often cannot change their practice environment.
The majority of personal health studies examined residents' mental health, specifically exploring mood states, depression, and burnout. Most studies examined only residents and did not compare their results to the general population or to nonphysician professional populations.
Mood states and emotions.
We found 20 studies related to residents' mood states and/or emotions. Eight studies were cross-sectional, while 12 followed residents longitudinally. Study methods varied from using loosely structured interviews to using validated survey instruments, such as the Profile of Mood States (POMS).23 The POMS was used in eight studies and is a 65-item survey instrument in which participants relate their current mood to specific sentences (such as “I feel tense today”) on a five-point scale from “not at all” to “extremely.” From this, six mood-related domains are described: “tension-anxiety,” “depression-dejection,” “anger-hostility,” “vigor-activity,” “fatigue-inertia,” “confusion-bewilderment.” All eight studies similarly found that emotions varied throughout the year. Two small longitudinal studies (one by Ford and Wentz24 and another by Uliana et al.25) found that of the mood states, only anger-hostility rose during the first year of residency.24,25 Another study found that along with anger, fatigue-inertia worsened throughout the year.26 Recently, Bellini et al.27 found that anger, fatigue, and depression all rose by the fifth month of internship. A survey of 207 psychiatry residency program directors found that 6.7% of their residents did not complete their current year of training and of those leaving, 26% left due to emotional illness.28 A similar study of 274 internal medicine residency program directors found that about 1% of residents took a leave of absence during training, representing 420 residents in a five-year period.29 Twelve of those residents on a leave of absence had unsuccessful suicide attempts, and eight had successful attempts. None of the studies found significant relationships between mood and performance.
Twenty-six studies examined the prevalence of depression among residents. Thirteen studies were cross-sectional, 12 were longitudinal, and one looked at both cross-sectional and longitudinal data. Of these studies, seven measured depression using self-reported symptoms, while 18 used validated scales, and one used a psychiatric interview. The two validated scales used most frequently were the Beck Depression Index (BDI)30 and the Center for Epidemiological Studies of Depression (CES-D).31 The BDI and CES-D are similar in length and are self-administered questionnaires that measure symptoms of depression. Both questionnaires involve answering questions regarding the frequency of symptoms. A score is allotted for each answer, and the total score places a person into a category of no, mild, moderate, or severe depression. Five studies measured depression using the BDI, finding that 7% to 15% of residents met the criteria for at least mild depression.32–36 The five studies using the CES-D found depression rates between 23% and 28%.37–41 The CES-D studies' findings were similar to findings by Valko and Paula in 1975.42 Theirs was the earliest study we found regarding depression in residents: approximately 30% of residents reported depression during their first year of residency. Thirty years later, Collier et al.43 reported a similar finding with 35% of internal medicine residents reporting significant depressive symptoms. None of these depression studies examined resident performance.
The Oxford dictionary defines burnout as “the state of being extremely tired or ill, either mentally or physically, because you have worked too hard.”44 We found four studies on burnout. All were cross-sectional, using the Maslach Burnout Inventory (MBI). This well-established inventory is a 22-item self-administered questionnaire that measures three components of burnout: emotional exhaustion, depersonalization, and personal accomplishment.45 Three of the studies used the same data set from a group of family medicine residents, but analyzed different aspects of that data.46–48 These family medicine residents showed moderate to high levels of burnout, with notable scores under emotional exhaustion and depersonalization. There was no significant gender difference in burnout rates. In the fourth study, 76% of internal medicine residents met criteria for burnout.49 Notably, burned-out residents self-reported a decrease in the quality of care they felt they provided to patients and lower levels of job satisfaction. This was the only study to link resident burnout with any aspect of resident performance.
Residents' physical health.
One study assessed the physical health of residents, although a second study did ask about residents' health on a portion of a locally developed questionnaire.50 Using several instruments, Godenick et al.35 surveyed 178 family practice residents in South Carolina regarding their psychological and physical health. Physical health was measured using weight, blood pressure, skin-fold thickness, cholesterol, and aerobic exercise tolerance. Residents' physical health was approximately the same as the health of age-adjusted norms for the general population in their 20s and 30s. The relationship between physical health and performance outcomes was not examined.
Social and financial factors
Eight studies examined the relationship between a resident's social support system and job stress.41,50–56 Social support was inversely correlated with stress in every study. These studies did not examine the relationship between social support and performance.
We found two studies on resident debt. Collier et al.43 found that 43% of over 4,000 responding internal medicine residents had a monthly disposable income of less than US$100, and 42% had educational debt above US$50,000. Average credit card debt was close to US$4,000.43 In the same study, only 10% of respondents indicated that salary had been consideration when choosing internal medicine as their specialty. Archer et al.55 found that lack of financial stability was a major stressor to responding residents. No study examined the relationship of debt to performance.
Response to job environment
Nineteen studies focused primarily on stress/distress as residents' response to their job environment. Three studies were longitudinal and 16 were cross-sectional. Nine studies developed their own questionnaires and ten used validated questionnaires, including the Physician Stress Inventory,57 Job Stress Index,58 Brief Symptom Inventory,59 Hassles Scale,60 Ways of Coping,61 Work-Related Strain Inventory (WRSI),62 and the General Health Questionnaire (GHQ).63 As an example, the WRSI was used in two studies and measures responses to 18 statements concerning personal productivity, co-worker relationships, and capacity to detach oneself from work-related stress when off-duty. All studies found that job-related factors such as fatigue, time demands, and role ambiguity were associated with higher stress.38–40,50–56,64–71 Interestingly, one group of investigators in the United Kingdom showed that general practitioners had higher levels of psychological distress than did the residents with whom they worked.69 This study was done after the United Kingdom made significant duty-hour reductions for residents; we found no data for the stress levels in these groups before the work-hour reductions. Schwartz et al.54 found that residents' stress was similar to the stress of a random sample of adults in the community of Rochester, New York. Only one study examined the association between stress and job performance, and found that residents with less stress and more positive attitudes had higher ratings on attending evaluations.64
We found 15 studies that looked at residents' job satisfaction. Nine were cross-sectional and six were longitudinal. None of these studies used questionnaires specifically on satisfaction. Two did use questionnaires for stress that included questions about job satisfaction (WRSI and GHQ). Booth and Smith67 surveyed a random selection of New Zealand residents who constituted a third of the resident pool. Of the 388 respondents, 66% were satisfied with their jobs, 20% were neutral, and 14% were dissatisfied. Overall, 28% reported they would not choose medicine again as a career. The other investigations attempted to identify aspects of residency training that might affect residents' satisfaction. Revicki et al.41 found that residents with greater role ambiguity had less job satisfaction. A random sample of 10% of residents who were members of the American Medical Association reported that higher job satisfaction during their internship correlated with more frequent attending contact, lectures, and patient rounds.62 Weaver et al.72 found that community-based family medicine residents reported higher job satisfaction, compared to university-based residents. Finally, a study of 19 surgical interns found that those on call every third night reported higher levels of satisfaction compared to those on every-other-night call.70 Neither the residents themselves nor the attending physicians supervising them identified significant differences in the frequency of patient care errors between call groups. This study was the only one to examine the relationship between job satisfaction and resident performance.
When using search terms “empathy,” “altruism,” and “community involvement,” we found three studies that analyzed positive responses to the job environment. All were longitudinal studies of internal medicine residents. The three scales used were Jefferson Scale of Physician Empathy,73 Interpersonal Reactivity Index,74 and The Emotion and Empathy Scales.75 All three studies found residents had decreased empathy toward patients as they progressed through their training. The studies did not attempt to link empathy with resident performance.
Attempting to understand physician performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding anything about the individual patient and his or her environment. We developed a model for conceptualizing the interactions of five domains of the individual physician's performance. Our study also examined the current state of the literature on contributors to resident performance. We found few discrete associations between the individual resident's factors and actual job performance.
Overall, we found more than 1,000 commentaries, opinion pieces, consensus statements, and theoretical articles about residency training and physician performance. However, we found fewer than 100 original research articles on residents' personal factors and fewer that studied work performance. Most of the studies focused on various mood states of residents (depression, anxiety, stress). Directionality of influence of these moods on other performance factors was not examined. In addition, we found scant research that covered the positive aspects of training or of being a physician (empathy, motivation, goals, positive emotions).
Our review paints a distressing picture of physicians in training. Stress, burnout, and fatigue levels are high. Levels of depression vary and can be quite high. There are low levels of job satisfaction. However, these studies did not examine the more positive and motivating aspects of medicine, such as a joyous interaction with a patient or a successful completion of a procedure. The unhappy picture has implications for recruitment of new medical students and residents, especially into fields (such as primary care) that are undergoing significant fiscal stresses with less autonomy of practice. Yet, because of the paucity of positive studies, one must question whether this picture is accurate.
Additionally, there are many gaps in this literature base. We found no studies that systematically reviewed patient care errors in relation to resident performance or mood state. We found very few studies that analyzed resident performance or aspects of patient care. We found no research articles on residents' learning style preferences, self-reflection about their practice, or personal preferences for practice as related to their performance. Educational articles focused almost exclusively on teaching methods and provided only cursory examinations of residents' inner states in relationship to their performances. The literature that relates health system variables and individual physician states to resident performance is indeed scanty.
This review has several limitations. First, given the broad scope of our model, we did not review all aspects of educational and medical infrastructure influences on performance. In addition, studies that developed their own survey instruments rather than using previously validated scales are difficult to interpret without comparison groups or populations. Using common scales, such as the POMS, in conjunction with new instruments allows for examination of scale validity and generalizability of results. Thus, when several groups of educators find rising anxiety and fatigue levels into midwinter, interpretation of the scores becomes simplified. We also did not examine the reliability and validity of the more than 60 scales used in these studies, as this was beyond the scope of this paper. Most studies usually relied on self-report, which is subject to recall bias and positive-negative reporting bias. In addition, the longitudinal studies only followed residents throughout their training. We do not know how these residents fared as practicing physicians.
Our model of individual factors contributing to resident performance outcomes builds on areas identified as important in the literature and on expert consensus to help frame future work in understanding physicians' performances. This hypothesis-generating model can be used to test how variations in motivation, physical health, and personal preferences might influence physician performance in specific domains. Testing this theoretical model in its entirety would be complicated. Given the number of variables, researchers would need to follow thousands of residents over several years to identify the contribution of the variables involved. Work in this research domain looks promising, since new accreditation standards require educators to document and track various aspects of physician performance. The next 20 years of educational research on physician performance will be aided by the creation and maintenance of new performance-related databases.
Our review examined only individual factors that might influence the performance of physicians. Many outcomes of interest to educators and policy stakeholders occur when an individual physician interacts with an individual patient in the context of his or her medical setting, and the application of his or her knowledge base in clinical setting. These decisions may range from a physician's prescription of a beta blocker for a patient after myocardial infarction, a decision to perform an exploratory laparoscopy, or a pleasant/positive interaction that would encourage medical follow-up. The full model including medical education and health systems infrastructure becomes more important as the focus on performance moves away from residents (in somewhat constant training environments) to practicing physicians who have greater variations and fewer checks and balances on their practice patterns.
Our review occurred during a time of unprecedented increases in physician and physician training oversight and calls for accountability in the field of medicine. Understanding current influences on physician practice, and developing a testable model of the influence of physician performance on patient outcomes, are essential to improving those outcomes.
The authors would like to acknowledge the contributions of Stephen Chen, MD, MBA, in the Department of Surgery at University of Michigan, Ann Arbor; Paul Cox, MD, in the Department of Psychiatry at University of California, Davis; and Daniel Pratt, MD, at University of British Columbia, Vancouver, British Columbia, Canada.
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