This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.

The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the American University of the Caribbean, the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine. Nor does any of this represent any position of the Northeast Georgia Medical Center or Northeast Georgia Health System.

Wednesday, May 16, 2018

I recently saw this really interesting article (1) in Medical Teacher, the official journal of AMEE.  The authors, Renee A. Scheepers and colleagues from the Center for Evidence Based Education at the University of Amsterdam, asked a great question: which personality traits affect a supervising physician’s doctor role and teacher role engagement? They were also trying to determine if engagement in work would have an affect on the association between teaching performance and a faculty member’s personality.  Of secondary importance to this study, but arguably as important overall as the engagement question was the idea that engaged physicians may experience less burnout.

The authors started out with the Five Factor model of personality traits (2) which has five separate domains, including conscientiousness, agreeableness, extraversion, emotional stability, and openness. Prior work had identified that conscientiousness is associated with engagement and dedication to work and may lead to improvement in teaching engagement. (3) 

As physician burnout continues to make headlines in the US, there has been precious little progress in helping the physician community to adequately respond.  Physician suicide is disproportionately higher than the general population. (4) Gonzalez-Roma and colleagues (5), noted that work engagement is the opposite of burnout, it’s a positive and active state of mind. Feedback, particularly on your performance as a teacher, may stimulate engagement, and interestingly be protective against burnout. 

This study took place in 61 residency programs that were located in 18 different hospitals (2 academic, 16 community) in the Netherlands. The authors invited 815 resident physicians to participate.  By the end of the study period, 67% of the residents completed evaluations on 805 / 819 supervising physicians. 78 percent of the supervising physicians self-reported personality traits using the BFI-10 (Big Five Inventory). The authors used the validated Utrecht Work Engagement Scale (UWES-9) to measure overall work engagement, but the measure also was able to separate engagement in their role as a physician from their role as a teacher.

The authors found that conscientiousness, extraversion, and emotional stability were all positively associated being engaged as a physician, while conscientiousness, extraversion, and agreeableness were associated with engagement as a teacher. They didn’t find any direct association between personality traits and teaching performance as evaluated by the residents. It seems that the physicians’ engagement explained more of the residents’ positive evaluations than any individual personality characteristic. But since having the characteristics of extraversion, agreeableness, and conscientiousness led to more engagement as a teacher, the residents liked their teaching style better.

So, some of this is a no-brainer! If you are more engaged, the residents will see you in a more positive light as a teacher. When students identify their best teachers, they often mention things like passion and excitement for the topic. That would also fit in the extraversion model.  Agreeableness may be a proxy measure of the atmosphere of a safe, non-toxic teaching environment that is promoted by great teachers.

The authors also made the observation that conscientiousness, while seen as a positive teaching characteristic may lead to increased stress on the physician work side of the equation because it also includes goal-directed and achievement-oriented behaviors. This can lead to overly high standards and higher stress levels in physicians. 

The bottom line is that engaged teachers receive better evaluations from residents for their teaching performance than do engaged physicians. Unfortunately, supervising physicians were more engaged in the physician work than they were for their teaching work. We need to work to identify ways to help supervising physicians build engagement with their teaching role, while continuing to support and build engagement in their physician role.

1. Scheepers RA, Araha OA, Heinemana MJ, Lombarts KM.  How personality traits affect clinician-supervisors’ work engagement and subsequently their teaching performance in residency training.  Medical Teacher  2016; 38 (11): 1105–1111.
2. McCrae RR, Costa PT. Validation of the five-factor model of personality across instruments and observers. J Pers Soc Psychol. 1987; 52: 81.
3. Akhtar R, et al. The engageable personality: personality and trait as predictors of work engagement. Pers Individ Differ 2015; 73: 44–49.
4. Schernhammer ES, Colditz GA. Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). Am J of Psychiatry  2004; 161(12): 2295-2302.
5. Gonzalez-Roma V, et al.  Burnout and work engagement: independent factors or opposite poles? J Vocat Behav 2006; 68: 165–174.

Saturday, November 25, 2017

Gender differences in Feedback

A study by Mueller and colleagues in last month’s Journal of Graduate Medical Education (1) looked at feedback given to emergency medicine residents over two years of residency training. The purpose of the study was to determine if there was a difference in the evaluations that resident received from attending physicians based on the resident’s gender. The authors were looking for the so-called “gender gap”. 

In order to determine if there was a gender gap, the authors performed a qualitative analysis of the evaluative comments that were made by attending physicians during milestone observations of residents. These comments were made in real time through a software application that was available on the attending physician’s mobile phone or computer. The comments were made by 67 attending physicians. 29 of the 67 attending physicians were female (47%).

The cohort included two classes of PGY-3 emergency medicine residents (n = 47). The gender breakdown of the residents included in the study is not clear, but it appears that the analysis was primarily of residents who received more than 15 comments during the study period.  In this group of 35 residents, there were 13 (37%) who were female.

There were a total of 1317 direct observation comments made during the two-year study period. The comments made by attending physicians seemed to value procedural and diagnostic skills, which makes sense for emergency medicine residents. Interestingly, the faculty also valued some particular personality traits such as confidence, hard work, the ability to perform under pressure, and multi-tasking.  The authors identified these characteristics as more stereotypically masculine traits.

The authors concluded that female residents received “less consistent feedback from attending physicians than male residents”. This was primarily focused on the concept of the emergency medicine valued personality traits. Female residents were more likely (no statistical analysis given) to receive both strong praise and strong criticism than male residents (62% vs. 45%). When considering the “ideal” emergency medicine traits, 50% of the men received negative comments compared to 77% of the women. 62 percent of the female residents were criticized by more than one attending for their lack of these idealized emergency medicine personality traits compared to 36% of the male residents.

In a 2014 qualitative study, Kolehmainen and colleagues performed semi-structured interviews with internal medicine residents who had participated in leading CPR in a hospital resuscitation. (2) They were trying to determine how gender influences the code leadership experience. One of the themes from this research was that female residents felt stress from violating “gender behavioral norms” in the role of code leader. It would be interesting to know if the female emergency medicine residents in the Mueller study felt pressure and stress at having to exhibit these stereotypically masculine traits in order to receive better evaluations from their faculty physicians. 

Many of you are probably thinking the same thing that I was thinking when I read this great manuscript: what about the gender gap in the evaluators. Interestingly, the authors did not even mention this concept. It was as if the attending physicians were considered above reproach, which we know is not true. Men and women evaluate differently. They value different characteristics, and may actually treat residents differently based on the resident’s gender.

In 2012, Moss-Racusin and colleagues (3) performed a randomized double-blind study of science faculty who were asked to rate the application materials of a graduate student who was applying for a laboratory position. The student was randomly assigned either a male or female name.  Faculty members rated the students with a male name significantly higher including being more competent and offering them a higher starting salary.

We published a study several years ago that looked at evaluation comments made by faculty and senior residents regarding first year residents on an inpatient rotation (4). We found some differences in the types of comments made by senior and junior level faculty and senior residents, but there were not enough female attendings to determine if there were any real gender differences in the evaluators. 

But half of the 67 evaluators in this study were women. Plenty to show a difference. I would love to see the comments broken down into the four pairs (Male faculty to Male resident, Female faculty to Female resident, Male faculty to Female resident, Female faculty to Male resident).

The author’s conclusion that this research “contributes to understandings of gender inequality in graduate medical education” is true, but they could have done much more. 

As usual, we invite your comments…

(1) Mueller AS, Jenkins TM, Osborne M, et al. Gender Differences in Attending Physicians’ Feedback to Residents: A Qualitative Analysis. J Grad Med Ed 2017; 10: 577-585.
(2) Kolehmainen C, Brennan M, Filut A, et al. Afraid of being ‘‘witchy with a ‘b’: a qualitative study of how gender influences residents’ experiences leading cardiopulmonary resuscitation. Acad Med  2014; 89 (9): 1276–1281.
(3) Moss-Racusin CA, Dovidio JF, Brescoll VL, et al. Science faculty’s subtle gender biases favor male students. Proc Natl Acad Sci USA. 2012; 109(41): 16474–16479.
(4) Ringdahl E, Delzell JE, Kruse RL. Evaluation of interns by senior residents and faculty: is there any difference?  Medical Education 2004; 38: 646–651.