EDUCATION/ORIGINAL RESEARCH

Resident Perspectives on ProfessionalismLack Common Consensus

Christine S. Cho, MD, MPH; Eva M. Delgado, MD; Frances K. Barg, PhD, MEd; Jill C. Posner, MD, MSCE

Volume 6

Study objective: We sought to characterize and understand the residents’ perspective on how professionalismdevelops through pediatric emergency medicine experiences.

Methods: Qualitative methods (freelisting—listing words associated with professionalism—and semistructuredinterviews) were conducted with senior emergency medicine and pediatric residents about their experiences rotating inthe emergency department of a large, urban, tertiary care, freestanding children’s hospital. All senior residents wereeligible, with purposive sampling to maximize demographic variability. Saliency (importance) of words was analyzed withSmith S scores and consensus analysis. Interviews were conducted until content saturation was achieved; transcriptswere coded by independent investigators to reach thematic consensus.

Results: Twenty-five interviews (36% emergency, 64% pediatrics) were conducted. Common words associated withprofessionalism were “respect,” “compassion,” “empathy,” and “integrity”; however, residents did not share a commonconsensus. The framework for how residents described the development of their professionalism includes observations,interactions, and environment. Examples include resident observation of role models; interactions with patients, families,and coworkers; self-reflection; and the unique environment of the ED. Residents believed that role modeling was the mostinfluential factor. Few reported receiving sufficient observation by attending physicians during their interactions withpatients and most reported receiving little direct feedback on their professionalism. Residents’ descriptions ofprofessionalism crossed multiple Accreditation Council for Graduate Medical Education (ACGME) competencies.

Conclusion: Residents displayed high variability in their understanding of professionalism, which was frequently atvariance with the corresponding ACGME competency definition. The resident perspective and understanding ofprofessionalism may usefully inform refinements in ACGME milestones and entrustable professional activities.[Ann Emerg Med. 2014;63:61-67.]

Please see page 62 for the Editor’s Capsule Summary of this article.

A feedback survey is available with each research article published on the Web at www.annemergmed.com.A podcast for this article is available at www.annemergmed.com.

0196-0644/$-see front matterCopyright © 2013 by the American College of Emergency Physicians.http://dx.doi.org/10.1016/j.annemergmed.2013.07.493

SEE EDITORIAL, P. 68

INTRODUCTIONProfessionalism is one of 6 Accreditation Council for

Graduate Medical Education (ACGME) core competenciesin which residents must achieve proficiency during residencytraining.1 Residency program directors in emergencymedicine and pediatrics have developed workbooks andtoolkits for the instruction of professionalism duringresidency.2,3 However, the efficacy of these types of curriculais not well described in the literature. In addition, there isconcern that “professionalism” and other core competenciesare artificial constructs that lack the ability to accuratelyrepresent the true clinical experience or allow accurateassessment.4-7

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Also lacking is a detailed exploration of the keystakeholder’s viewpoint, that is, the resident. Little is knownabout the way residents regard professionalism, how theylearn about professionalism in the emergency department(ED), and whether their perspectives align with those of theACGME. A handful of studies on resident professionalismare focused in other subspecialties or lack depth ofexploration of this key stakeholder’s perspective.8-13 To date,to our knowledge no studies have examined how residentsperceive the effect of ED rotations on the development ofprofessionalism.

Pediatric emergency experiences in particular may offerunique challenges to and experiences with professionalismdevelopment in the ED. The goal of this study was toexplore the resident’s perspective on the development ofprofessionalism through experiences in a pediatric ED.

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Table 1. Resident characteristics (n¼25 of 56 total possible).

Average age (range), y 31 (28–36)Residency, %Pediatrics—end of PGY-3 64Emergency medicine 36

End of PGY3/PGY4 44/56Male 40Marital status, %Single 56Married 44

Have children, % 24Medical school/residency immediately after college, % 64Average length of interviews (range), min 34 (19–58)

Resident Perspectives on Professionalism Cho et al

Editor’s Capsule Summary

What is already known on this topicProfessionalism is a mandated competency under USstandards for emergency medicine training but maynot be consistently understood within residencyprograms.

What question this study addressedThe authors assessed senior resident interpretations ofprofessionalism and relevant training elements duringa pediatric emergency rotation in an urban academicmedical center.

What this study adds to our knowledgeResidents within a single medical center vary widelyin their understanding of professionalism as a clinicalcompetency and in their assessments of effectivelearning modalities.

How this is relevant to clinical practiceTrainees and evaluators must have a sharedunderstanding of the definition of professionalismbefore they participate in evaluations of competencyin this area.

Through eliciting this perspective, we sought a morecomprehensive understanding of how trainees viewprofessionalism and how they perceive it is (or is not) acquired.

MATERIALS AND METHODSSetting

This was an institutional review board–approved, single-institution study at the Children’s Hospital of Philadelphia, afreestanding, urban, tertiary care, children’s hospital whose EDevaluates more than 85,000 patients a year. At the time of thestudy, pediatric and emergency medicine residents (Hospital ofthe University of Pennsylvania) spent at least 1 month every yearin the ED, for a total of 500 to 600 clinical hours duringresidency. At that time, no regular professionalism didacticcurriculum existed in the pediatric ED. The emergency medicineresidents had a 2-hour orientation didactic, 1 didactic session peryear, and 1 journal club every 2 years about professionalism. Thepediatric residents had a 1-hour didactic during orientation, aswell as monthly evening journal club sessions on professionalism.

Selection of ParticipantsPurposive sampling was used, in which only senior

pediatric residents post-graduate year (PGY) 3 in the lastmonth or within 3 months after completion of their training)and emergency medicine residents (PGY-4 or finishing PGY-3)

62 Annals of Emergency Medicine

were eligible (56 total). All eligible subjects were initiallycontacted by e-mail; demographic variability was maximizedby 1 author (C.S.C.) generally monitoring and balancingparticipant characteristics (Table 1) when choosing subjects tointerview.14 To maintain participant anonymity, the year ofdata collection is concealed.

Given the lack of knowledge about the resident’s perspective,qualitative methodology was ideal to obtain rich, descriptivedata. Semistructured interviews were chosen for their open-ended nature and detailed exploration of viewpoints14 and wereconducted with an interview guide and basic questions. Theinterviewer did not strictly adhere to one set of questions, butrather followed the lead of interviewees’ responses to explore newideas as they were introduced. Freelisting was used during theinterview as an additional method of gaining insight into howresidents defined and conceptualized the idea of professionalism.Freelisting is a systematic data collection method in which theinterviewee is asked to list all words they can associate with agiven concept—in this study, professionalism.14-16 It was used toassess whether a common consensus existed among the residents.In our study, subjects were asked to list all words that came tomind that they associated with or used to define the word“professionalism.”

The interview guide was developed based on Bandura’ssocial cognitive theory, a learning theory that underscoresobservation as a primary method of acquiring knowledge.17

The theory also incorporates the relationships betweenenvironment, person, and behavior as an important part oflearning.17 The investigators believed that Bandura’s socialcognitive theory was most applicable to resident experienceswith professionalism in the ED and used it as a theoreticalbasis for investigation. The 2 primary pediatric emergencymedicine investigators created an open-ended question guide18

(Appendix E1, available online at http://www.annemergmed.com) that was reviewed and developed further by a thirdinvestigator with expertise in qualitative research design. Toassess face validity, 15 pediatric emergency medicine attendingphysicians and fellows reviewed the content of the questionguide, and it was modified accordingly.

A trained interviewer conducted all interviews. Thisinterviewer was chosen specifically for her familiarity with clinicalmedicine and the hospital setting but lack of personal

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Table 2. Freelist words associated with “professionalism.”

No. ofTimes Listed Words

12 Respect*9 Knowledge6 Compassion*5 Appropriate, empathy*4 Collegiality, communication, confidence, ethics,* integrity,*

interactions (with patients), kind,* nonjudgmental,punctual, quality, responsibility,* role model*

3 Interactions (with families), leadership, mature, patience,patient care, trust

2 Appearance, awareness, balance, confidentiality, courtesy,dealing, dignity, diligence, equality, honesty, interactions(with colleagues), interpersonal, open-minded,patient-centered, pleasant, politeness, positive,separation, skills, smart, tolerant

Cho et al Resident Perspectives on Professionalism

relationship with the trainees or their evaluation. Beforeinitiation of the study, the interviewer spent time in the ED toobserve and become familiar with the environment. Three pilotinterviews were conducted to hone the interviewer’s techniqueand further refine the question guide. There was no a prioridetermination of how many interviews would be conducted; theywere conducted until thematic saturation was obtained.

Data Collection and ProcessingAll interviews were conducted in a private room and

audiotaped; the interviews were transcribed by a third-partyservice, with removal of all personal identifiers. Afterward, theinterviewee completed a short demographic questionnaire.Interviewees were given a $10 bookstore gift certificate ascompensation for their time.

*Most salient words.

Primary Data AnalysisFor freelists, we used Anthropac,15 a software program

specifically designed to analyze freelists. For each word,Anthropac was used to calculate a saliency score (Smith’s S) usingthe formula S¼((

P((L–Rjþ1))/L)/N, where L¼the length of

each list, Rj was the rank of item J in the list, and N¼the numberof lists in the sample.16 Saliency describes the words that are mostimportant for defining the domain of interest among members ofa group and is based on how early and often words are presented.Saliency scores were then plotted as scree plots, and the graphwas inspected to select the elbow that demarcated a flattening ofthe slope. All words with saliency scores greater than or equal tothat elbow value were retained as the list of salient terms.

Consensus analysis procedures were used to analyze thetheoretical perspective of whether culture is knowledge that isshared and socially distributed among individuals.19 The freelistprocedure in Anthropac created a respondent-by-item matrix thatwas then used as input for consensus analysis. Data analysescentered on determining the degree of similarity amongrespondents, freelisted words.20 These analyses producedeigenvalues that revealed the strength of the consensus. Aneigenvalue is the total amount of variance that is explained by afactor.21 A first eigenvalue that is at least 3 times larger than thesecond indicates a strong agreement among respondents.19 Ratiosless than 3:1 imply that there may be more than 1 “culturallycorrect” definition of the domain.

All interview transcripts were independently reviewed by 2investigators (C.S.C. and E.M.D.); content analysis wasconducted with constant comparative technique in an iterativeinductive process.14 To minimize bias, one coder (C.S.C.) wasinvolved in the development of the question guide and thesecond (E.M.D.) was not.

After initial independent review, both investigators developeda coding list of general themes. It was discussed and reviewedthrough 3 rounds of peer debriefing until consensus wasachieved. A second independent review of all transcripts wascompleted by both investigators. Final coding was compared andremaining discrepancies were discussed and resolved.

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RESULTSInterviews were conducted, and after the 22nd one no new

themes emerged from the analysis (content saturation). Threeadditional interviews were conducted to ensure that contentsaturation was truly achieved. The interviewees had a widevariety of characteristics, as summarized in Table 1.

Through freelisting, residents identified 129 unique wordsthey associated with the term “professionalism.” The mostcommon words are displayed in Table 2. Saliency wascalculated: “Respect,” “compassion,” “empathy,” and“integrity” were the 4 most salient terms that the residents usedto define professionalism (Smith S salience scores 0.22, 0.2,0.14, and 0.13, respectively, with elbow value of 0.13). Thesewere followed by “role model,” “kind,” “responsibility,” and“ethics.” Despite having some common terms, a consensusanalysis showed eigenvalues of the first factor were less than3 times larger than the second, suggesting that residentslacked a shared, core construct on how they defineprofessionalism.

When asked whether professionalism is important, allresidents answered in the affirmative. Residents were then asked,“Why is professionalism important?” A variety of reasons wereput forth. Patient-related reasons included patient satisfaction,improved rapport, ability to obtain a more accurate history,improved patient adherence, and positive patient outcomes. Asan example, one resident said, “The patient is going to trust youmore.. [E]verything has more weight when it’s delivered bysomeone who is professional.”

In addition, personal factors such as personal satisfaction,efficiency, and reduced malpractice risk were also listed. “Ithink you derive some benefit from it.. [Y]ou feel goodabout what you do, and it makes it easier for everyone youwork around to get their job done.” Many residents alsodiscussed how acting professionally was important because it ispart of the duty of being a physician. As one resident stated,“It speaks to the core in my mind why you are a doctor.. [I]t

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Figure 1. Resident quotes about learning professionalismthrough observation.

Resident Perspectives on Professionalism Cho et al

speaks to the core doctrine of how to be a good doctor. Thepoint is putting patients first.”

All residents believed that the pediatric ED was a formativeplace for learning about professionalism during residency. Aframework was developed from iterative coding and analysis ofthe themes that emerged from the interviews. The frameworkcenters on the resident and has 3 features: observations,interactions, and the ED environment. Each aspect is discussedin more detail below.

The most common theme that emerged was that residentsbelieved they learned about professionalism throughobserving attending physician behaviors and role modeling.“I think that the great thing about the ED is that you canreally observe the attendings interact with patients andfamilies.” Another resident explained in more detail, “Youget to observe people’s styles, so you get to develop yourown style of professionalism by observing how other peopledo it. By and large I think it’s done incredibly well bymany, many different attendings who have many differentstyles, so the whole point of professionalism is developingyour own style of doing things.”

Observing other ED staff was also important to residents. Forexample, “The nurses in the ED are great. They’re very efficient.They’re very good at calming families down. People come in, in ahigh anxiety level because it’s an emergency room and.I learneda lot from them about how to keep calm.” See Figure 1 foradditional quotes.

Residents spoke of interactions with patients and families asinfluential in how they learn about professionalism. One EDresident stated, “I’ve learned to understand that parents’ naturalinclination is to want to look out to protect their kid. I thinkkind of seeing it from their perspective; I’ve learned not todiscredit what the parents have to say.” Feedback from familiesalso plays a role: “At the end of the whole visit, the mom and thekid said, ‘Thank you for your time; thank you for listening. Ireally feel better.’ There was satisfaction there so that tells me Iwas able to communicate.. [T]hat’s important to me.”

Some ED residents described how pediatric patientinteractions differed from their adult patient experiences.“Parents of chronically ill children have a ton of knowledge..[T]hese are parents that have a lot to offer and can help you growas a physician.” Another shared, “I think the anxiety level here isa bit higher than it is in the adult sectors because you’re dealingwith children.. I think dealing with a frustrated parent andbeing able to maintain a certain level of professionalism.helpsyou in all aspects of life.”

Pediatric emergency medicine–specific clinical cases wereoften listed by the residents as a way they learned aboutprofessionalism. These included worried parents of children withminor illness, pediatric trauma, critically ill resuscitations, newdiagnosis of severe illness (in particular, cancer), child abuse, anddeath. “The ED [is] particularly a place where there are somedifficult social things, where professionalism is incrediblyimportant. I know dealing with different cases of abuse,trauma—these are the things I think really play a part.”

64 Annals of Emergency Medicine

Residents spoke frequently of learning about professionalism byworking closely with ED staff, some of whom were the same rolemodels they learned from by observation: attending physicians,nurses, fellows, and other residents, as well as consultants, clerks,and other support staff. This is exemplified by the quote from apediatric resident: “In the ED we work right alongside them (staff,RN, RT, etc) in a way that we don’t in other parts of the hospital,so I think they have a really big influence on our training.”Anotherpediatric resident said, “There is no other division where you getthis much contact with the attendings.”

Residents also described difficult interactions with staff: “Inthe ER, the nurses are notorious for being very hard on theresidents.. [I]t’s like a hazing process, so it’s hard to actprofessionally when people are treating you like you don’t knowanything when sometimes you actually do.”

Another frequently described challenge was working withconsultants: “It’s because they’re on the phone, they don’tknow the patient; they’re not in person. And I think peopleare a little disinhibited on the phone when they’re in a badmood or they just don’t like what they’re hearing on thephone.” All comments about consultants emerged whenresidents were asked about unprofessionalism in the EDsetting. For example, “From the consultants I learned how notto do consults. I think that some of the consulting servicesdon’t do a good job of taking care of the ED, some.[are]reluctant to come down here to the emergency room andwhen you see it from the emergency room side, you see howhard that can be and so I’ve learned availability.”

Self-reflection is the third type of interaction that was describedby residents as a way they learned about professionalism. “It’songoing. You can always bemore professional. Even if you recognizewhat truly the definition of professionalism is, you need to constantlyreevaluate yourself, making sure that you’re demonstratingprofessionalism.. It never stops, should never stop.” Residentsdescribed self-awareness and self-control when dealing withchallenging situations in the ED. “You need to take a step back.putyourself in their shoes, and do whatever you need to do to empathizeor sympathize but clear the obstacles or the barriers to providingthemwith the bestmedical care.”However,many residents describednot having the opportunity or taking the time to reflect on

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Figure 2. Resident quotes on how the ED environment affectsthe development of professionalism.

Cho et al Resident Perspectives on Professionalism

experiences. “I don’t really think about it.... I try to practice thatway.but I usually don’t sit down and think about that sort of thing.”

The ED environment was frequently described as importantin how residents learned about professionalism. The openphysical environment, high volume of patients, unpredictabilityof patient flow, time constraints for clinical care, intense activityduring shifts, and close proximity to a variety of staff andcolleagues were all listed as aspects of environment that affectedthe residents’ development of professionalism. Resident quotesthat relate to this theme are included in Figure 2.

Most residents believed that lectures and didactic sessionswere not useful for teaching professionalism. “I thinkprofessionalism can be taught, not in a classroom, but.byexample.” They also recognized that the opportunity to beobserved in an interaction might promote further learning orfeedback on their development of professionalism. When askedabout the optimal way to receive feedback, one resident repliedthat it would be helpful to have “attendings watching you interactwith your colleagues, other residents you’re working with, with thenurses, with the technicians, with the patient’s family.on the jobobservation, not a fake patient scenario.” Residents also identifiedcritical incident debriefing as a useful mode of learning aboutprofessionalism. “When we have a gravely ill patient, if someonepasses away in the ED.bringing the group together, regrouping,talking about it, [and] making it a learning experience.bringseverybody back to their center, and that way we can go and step outand take care of another patient.”

Only 6 (24%) residents reported receiving any feedback fromattending physicians about their professionalism. The feedbackthat residents did describe was minimal and nonspecific such as“Great job” or “Oh good, you’re here tonight, it’s going to be agood night.” Most residents wished for more opportunities fordirect observation by attending physicians: “I get less feedbackfrom attendings as far as good interactions or bad interactions,just because they are not there—you’re relaying the story to thembut it’s not necessarily in front of the patient and their family.”As another resident explained, “[I]n general we usually don’t seekids with attendings; we see them separately and then we talkabout it, and then we go back separately.”

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LIMITATIONSAlthough qualitative research aims to study a wide variety of

perspectives in a detailed manner, the generalizability of theseresults is unknown. Trainees at other residency programs mayhave varying perspectives and experiences because of differentpersonal, curricular, and clinical experiences. These experiencesare not only affected by the characteristics of the ED in whichthey rotate but also their own individuality. It is also unknownwhether these findings are generalizable to trainees in otherspecialties.

DISCUSSIONAll residents interviewed described professionalism as an

important attribute of being a physician and highlighted thepediatric ED as a formative place for learning aboutprofessionalism. However, there was a striking lack of consensuson the definition of professionalism, as shown by consensusanalysis, the relatively low salience scores for even the mostcommonly used words to describe professionalism, and the factthat the experiences and behaviors described by residents in thisstudy as “professionalism” cross into all the ACGME corecompetencies. The ACGME defines competency inprofessionalism as demonstrating (1) compassion, integrity, andrespect for others; (2) responsiveness to patient needs thatsupersedes self-interest; (3) respect for patient privacy andautonomy; (4) accountability to patients, society, and theprofession; and (5) sensitivity and responsiveness to a diversepatient population.”1 Compatible with that definition, residentsmost associated the words “respect,” “compassion,” “empathy,”and “integrity” with professionalism. However, in total, 129different words were associated by residents with the word“professionalism.” In addition, residents associated all corecompetencies in their ideas of professionalism, in particularinterpersonal skills and communication and patient care. TheACGME outcome project attempted to create discretecompetencies, but the residents’ variable interpretation ofprofessionalism underscores the difficulties in using thesesynthesized constructs (in particular during formative andsummative evaluation) and the need to clarify terminology. Inone systematic review, valid measurement tools could not befound that assess individual competencies.5 Lurie suggested thatit would be better to “abandon the project to ‘assess thecompetencies’ in favour of empirical studies to define measurablefactors that do underlie human performance in the clinicalsetting.”6 Our study adds empirical resident-level data supportingthat the “professionalism” competency is not necessarilyunderstood or interpreted in the manner it was defined by theACGME.

The ACGMEMilestone Project has broadened this discussionby laying out developmental steps that are to be achieved forattaining various competencies.22,23 Achievement ofdevelopmental milestones in professionalism includesprofessionalization, professional conduct, humanism, andcultural competence. But the experiences around professionalism

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Resident Perspectives on Professionalism Cho et al

described by residents again cross into other milestones. Thefuture movement of competencies and milestones to entrustableprofessional activities may be one solution in incorporatingprofessionalism into more measurable behaviors.24 Our studymay add to the development of entrustable professional activitiesin pediatric emergency medicine by identifying residentbehaviors, challenges, and developmental perspectives.

One aspect that residents do identify as important for theirprofessionalism development was learning through rolemodeling. It was identified as one of the primary methods oflearning about professionalism in the ED, similar to findings inprevious studies in other fields.8,10 In particular, residents learnedfrom watching attending physicians interact with patients, otherphysicians (including residents), and staff (in particular, nurses).The ability to frequently observe attending physicians innumerous and varying clinical situations is unique to the ED andmakes it an ideal laboratory in which to study professionalism.

Despite the opportunities for learning about professionalismthrough observation of role models, it is notable that residentsdescribed feeling underobserved by their attending physicians.Unfortunately, residents also believed they received little formalevaluation and feedback with respect to their ownprofessionalism. One reason could be lack of or ill-definedexpectations for attending physicians to give feedback. Anothercould be inadequate knowledge, training, or comfort inproviding evaluation and feedback. The time pressures ofclinical work in the ED may also prohibit formative feedbackduring the shift. In a survey of emergency medicine residencydirectors, assessment methods were commonly described asinadequate in identifying serious professionalism issues.25

These barriers should be explored further, as commented on ina review of the literature on role modeling that also emphasizedthe need for better understanding of the attributes of good rolemodels, faculty development, and assisting learners in reflectionon experiences.26 A recent study of medical student narrativesreflecting on ED experiences identified an example of howwritten reflections on professionalism may be one method touse.27 Most residents in our study did not believe that didacticlectures were useful in the development of theirprofessionalism.

The results of our resident interviews provide a betterunderstanding of how residents view their development ofprofessionalism. Given the variability in how residents viewprofessionalism, in particular how residents do not share acommon viewpoint and that their perspective on professionalismencompasses various ACGME competencies, more clarity in itsdefinition may help to improve fostering professionalismeducation. In our small study, the ACGME definitions andconcepts around professionalism have not been shown to be validfor all learners; curriculum and evaluation requirements based onthose concepts may be problematic. The resident perspective iscrucial in developing a well-rounded understanding ofprofessionalism and may help create more explicit definitions,foster learning of professionalism, and specify behaviors used increating educational milestones.

66 Annals of Emergency Medicine

Supervising editor: Peter C. Wyer, MD

Author affiliations: From the Departments of Pediatrics andEmergency Medicine, UCSF Benioff Children’s Hospital, UCSFSchool of Medicine, San Francisco, CA (Cho); the Division ofEmergency Medicine, The Children’s Hospital of Philadelphia,Perelman School of Medicine, University of Pennsylvania,Philadelphia, PA (Delgado, Posner); and the Department of FamilyMedicine and Community Health, Perelman School of Medicine,University of Pennsylvania, Philadelphia, PA (Barg).

The authors acknowledge Harjeet Sembhi, MPH, for her work as aninterviewer.

Author contributions: CSC and JCP conceived the study andsupervised the conduct of the study and data collection. CSC,FKB, and JCP designed the study. CSC recruited subjects andmanaged the data. All authors analyzed the data. FKB providedstatistical support. CSC drafted the article, and all authorsprovided substantial revisions. CSC takes responsibility for thepaper as a whole.

Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article as per ICMJE conflictof interest guidelines (see www.icmje.org). The authors have statedthat no such relationships exist.

Publication dates: Received for publication June 27, 2012.Revisions received November 25, 2012; June 5, 2013; and June27, 2013. Accepted for publication July 10, 2013. Available onlineAugust 12, 2013.

Address for correspondence: Christine S. Cho, MD, MPH,E-mail christine.cho@ucsf.edu.

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