Abstract
Background
Early identification of emergency medicine (EM) residents who struggle with educational attainment is difficult. In‐training examination (ITE) scores predict success on the American Board of Emergency Medicine (ABEM) Qualifying Examination; however, results are not available until late in the academic year. The noncognitive trait “grit,” defined as “perseverance and passion for long‐term goals,” predicts achievement in high school graduation rates, undergraduate GPA, and gross anatomy. Grit‐S is a validated eight‐question scale scored 1 to 5; the average of responses represents a person’s grit. Our objective was to determine the correlation between EM resident Grit‐S scores and achievement, as measured by MCAT percentiles, ITE scores, and remediation rates.
Study Design and Methods
This was a 1‐year prospective, multicenter trial involving ten EM residencies from 2017 to 2018. Subjects were PGY‐1 to ‐4 EM residents. Grit‐S scores, MCAT percentile, remediation rates, ITE scores, and the ITE score’s prediction of passing the ABEM Qualifying Examination were collected. Correlation coefficients were computed to assess the relationship between residents’ grit and achievement.
Results
A total 385 of 434 (88.7%) residents participated who completed the Grit‐S as part of a larger study. The mean Grit‐S score was 3.62. Grit positively correlated with the predicted likelihood of passing the ABEM Qualifying Examination (r = 0.134, n = 382, p = 0.025). There was no correlation between grit and remediation (r = −0.04, n = 378, p = 0.46) or grit and MCAT percentiles (r =− 0.08, n = 262, p = 0.22).
Conclusions
The positive correlation between Grit‐S scores and percent likelihood of passing the ABEM Qualifying Examination demonstrates grit’s potential to assist residency leadership in early identification of residents who may attain a lower ITE score.
Introduction
Early identification of emergency medicine (EM) residents who struggle with educational attainment can be difficult. The EM In‐Training Examination (ITE) is administered every February. Residents who attain higher ITE scores have a higher likelihood of passing their American Board of Emergency Medicine (ABEM) Qualifying Examination.1, 2 This information is incredibly valuable to program leadership as they seek to assess medical knowledge both for competency‐based evaluations and to identify residents who may need additional guidance. Unfortunately, the results of the ITE are not available until late in the academic year resulting in a potential delay in identifying residents who may benefit from study plans and resources implemented at the beginning of residency to improve their medical knowledge.
In recent years, there has been increasing interest in using assessments of noncognitive traits to predict achievement.3, 4, 5, 6, 7, 8 Noncognitive traits, including personality, have been shown to predict academic performance and educational achievement.3, 4, 5, 6, 7, 8 The noncognitive trait “grit,” defined as “perseverance and passion for long‐term goals,” is a means to quantify an aspect of personality.3 Beyond intelligence, grit entails the vigor, interest, and effort required to attain a goal through adversity and failure. It seeks to help answer the question of why individuals of equal intelligence may achieve different levels of success.3 Grit has been shown to be stable over time in the short‐term in different populations,4, 9 but does seem to increase over time in the long term.3 The Short Grit Scale (Grit‐S) is a validated eight‐question scale scored 1 to 5, with 5 being the highest score. The average of the responses represents a person’s grit; the higher the score, the “grittier” the individual.4
In nonmedical domains, grit has been shown to predict educational attainment and success in multiple arenas including spelling bees, high school graduation rates, undergraduate GPA, and retention of recruits at West Point.3, 4, 10, 11, 12, 13 However, studies evaluating grit in medicine are limited, especially with respect to achievement in graduate medical education. Grittier medical students have been found to have higher class ranks and to be more successful in gross anatomy and grit correlates with surgical residents’ psychological well‐being.9, 14, 15, 16 However, to the best of our knowledge, there has been little research evaluating grit’s correlation with academic achievement in graduate medical education, and no study to date has assessed the association of grit and achievement in EM residents. Because grit has been shown to correlate with achievement and academic success and less “gritty” individuals have lower achievement in other domains, we sought to evaluate whether EM residents’ grit would correlate with their medical knowledge and thus academic achievement. Specifically, the purpose of this study was to evaluate whether Grit‐S scores correlated with residents’ ITE scores, MCAT percentiles, and need for remediation.
Materials and Methods
Study Design
This study was a secondary analysis of a larger multicenter prospective educational trial investigating the effectiveness of a wellness didactic curriculum and involved 10 ACGME‐accredited EM residency programs in the United States, conducted over 1 year from 2017 to 2018. The residency programs that participated in the study were geographically varied from the midwest, south, southeast, and west coast. The study was reviewed by each institution’s institutional review board and received approval at each site prior to study initiation. Eight sites were postgraduate year (PGY)‐1 to ‐3 residencies and two sites were PGY‐1 to ‐4 residencies.
Subjects
Eligible subjects for this study were PGY‐1 to ‐4 EM residents at the participating programs during the study period. There were no exclusion criteria. Participation in the survey study was voluntary, and incentive for participation was nominal and site‐specific.
Study Protocol
Written informed consent was obtained from all study participants. In February 2017 and February 2018, we administered the Grit‐S (Data Supplement S1, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10399/full) as part of a larger survey that also included demographic information, the Maslach Burnout Inventory,17 the Prime‐MD PHQ‐2 depression screen, and a career satisfaction scale.18, 19 Participants also self‐reported their MCAT scores and year taken. Based on the Association of American Medical Colleges’ historical percentile ranks for the MCAT, self‐reported raw MCAT scores were converted to percentiles for the corresponding year taken for uniformity.20 The survey was administered either as a paper survey or via online proprietary survey21 at the preference of each site investigator. Study principal investigators at each site collected data regarding participants’ ITE scores, their percent chance of passing the ABEM Qualifying Examination based on their ITE scores, and whether the resident underwent remediation, defined as “any extra work required for a resident above that required of all residents excluding counseling without additional work requirements.” ABEM’s reporting of ITE scores includes a raw score, percentile, and percent likelihood of passing the ABEM Qualifying Examination. Each resident was assigned a unique identifier known only to the individual participant and the respective site investigator. Follow‐up for nonresponders was program‐specific, either in person or via e‐mail.
Data Analysis
Categorical outcomes were summarized with frequencies and percentages and continuously distributed outcomes were summarized with the sample size, mean, and standard deviation (SD). The assessment of grit stability over a 1‐year period was assessed with a paired t‐test. A Pearson’s product‐moment correlation coefficient was computed to assess the relationship between residents’ Grit‐S scores and their MCAT percentiles, the ITE score’s prediction of passing the ABEM Qualifying Examination, and the change in ITE score’s prediction of passing the ABEM Qualifying Examination over a 1‐year period. A Spearman’s Rho correlation coefficient was computed to assess the relationship between residents’ Grit‐S scores and their need for remediation. Multivariable ordinary least squares regression was used to model the effect of Grit‐S scores, MCAT percentiles, and the need for remediation on the ITE score's prediction of passing the ABEM Qualifying Examination.
Results
A total of 385 of 434 residents completed the Grit‐S as part of a larger study for a response rate of 88.7%. The mean (±SD) age of participants was 30 (±3.1) years. The participants were 69% male and 31% female (Table 1).
Table 1.
Demographics of Participants
| Participant Characteristics (n = 385)* | |
|---|---|
| Age (years), mean (±SD)† | 30 (±3.1) |
| Gender, n (%)‡ | |
| Male | 248 (69.1) |
| Female | 111 (30.9) |
| Ethnicity, n (%)§ | |
| Caucasian | 277 (74.7) |
| Mixed | 25 (6.8) |
| Latino | 18 (4.9) |
| East Asian | 17 (4.6) |
| African American | 13 (3.5) |
| South Asian | 12 (3.2) |
| Middle Eastern | 8 (2.2) |
| Pacific Islander | 1 (0.3) |
| EM PGY, n (%)|| | |
| PGY‐1 | 167 (43.4) |
| PGY‐2 | 109 (28.3) |
| PGY‐3 | 91(23.6) |
| PGY‐4 | 18 (4.7) |
| Grit‐S score, mean (±SD) | 3.62 (±0.55) |
PGY = postgraduate year.
385 of 434 participants completed a Grit‐S.
Age at time of first completion of Grit‐S, n = 368; 17 participants did not indicate age.
n = 359; 26 participants did not indicate sex.
n = 371; 14 participants did not indicate ethnicity.
PGY at time of first completion of Grit‐S.
The mean (±SD) EM resident Grit‐S score was 3.62 (±0.55; Table 1). Of the residents with at least one Grit‐S score, 96 of 385 (24.9%) residents completed a Grit‐S 1 year apart (2017 and 2018). The 289 residents that only had one Grit‐S score did not complete two Grit‐S scales either because they graduated before the second administration, they were not yet residents during the first administration, or because they did not participate in one administration of the survey. Grit‐S remained stable from 2017 to 2018; there was no statistically significant difference between the Grit‐S scores in 2017 (3.59 ± 0.46) and 2018 (3.58 ± 0.56; p = 0.8733; Table 2).
Table 2.
Assessment of Grit Stability Over 1‐Year Period
| Grit | n | Mean | SD | p‐value* |
|---|---|---|---|---|
| February 2017 | 96 | 3.59 | 0.46 | 0.8733 |
| February 2018 | 96 | 3.58 | 0.56 |
Paired t‐test.
There was no correlation between Grit‐S score and MCAT percentile (r = −0.077, p = 0.216) or Grit‐S score and remediation (r = −0.050, p = 0.325). There was a positive correlation between Grit‐S score and the ITE score prediction of passing the ABEM Qualifying Examination (r = 0.134, p = 0.025; Table 3).
Table 3.
Correlations Between Grit‐S Score and Resident Achievement
| Correlation Coefficient | p‐value | |
|---|---|---|
| MCAT percentile* | −0.077† | 0.216 |
| Remediation | −0.050‡ | 0.325 |
| ITE Score prediction of passing ABEM Qualifying Examination§ | 0.134† | 0.025 |
ABEM = American Board of Emergency Medicine; ITE = In‐Training Examination.
n = 253; 132 participants did not indicate MCAT score.
Pearson’s correlation coefficient.
Spearman’s rho.
n = 279; 279 participants had both a 2017 Grit‐S and a 2017 ITE score available.
When controlling for MCAT percentile and need for remediation, for each one‐point increase in Grit‐S score, there was an increase of 2.30 (95% confidence interval [CI] = 0.45 to 4.15) percentage points in the chance of passing the ABEM Qualifying Examination. When controlling for Grit‐S score and need for remediation, for each 1% increase in MCAT percentile, there was an increase of 0.08 (95% CI = 0.01 to −0.015) percentage points in the chance of passing the ABEM Qualifying Examination. When controlling for Grit‐S score and MCAT percentile, the need for remediation predicted a decrease of 9.78 (95% CI = −12.71 to –6.85) percentage points in the chance of passing the ABEM Qualifying Examination (Table 4).
Table 4.
Ordinary Least‐squares Regression of Predictors of ITE Score Prediction of Passing ABEM Qualifying Examination
| Coefficient | 95% CI | p‐value * | |
|---|---|---|---|
| Grit‐S score | 2.30 | 0.45 to 4.15 | 0.015 |
| MCAT percentile | 0.08 | 0.01to 0.15 | 0.033 |
| Remediation | −9.78 | −12.71 to −6.85 | 0.000 |
ABEM = American Board of Emergency Medicine; ITE = In‐Training Examination.
Regression analysis.
There was no correlation between Grit‐S score and change in ITE scores over a 1‐year period, from 2017 to 2018 (r = −0.060, p = 4.27). Table 5 shows Grit‐S scores and ITE percentiles by PGY.
Table 5.
Grit‐S Scores, ITE by PGY
| Grit‐S score, mean (±SD)* | |
| PGY‐1 | 3.67 (±0.56) |
| PGY‐2 | 3.61 (±0.51) |
| PGY‐3 | 3.55 (±0.57) |
| PGY‐4 | 3.62 (±0.65) |
| ITE score, percentile (±SD)† | |
| 2017 ITE† | 65.53 (±24.98) |
| PGY‐1‡ | 68.72 (±23.83) |
| PGY‐2§ | 61.37 (±22.56) |
| PGY‐3|| | 65.69 (±27.69) |
| PGY‐4¶ | 71.94 (±26.78) |
| 2018 ITE** | 62.49 (±26.39) |
ITE = In‐Training Examination; PGY = postgraduate year.
PGY at time of first completion of Grit‐S.
n = 279; 279 participants had both a 2017 Grit‐S and a 2017 ITE score available.
n = 81.
n = 93.
n = 87.
n = 18.
n = 176; 176 participants had both a 2017 Grit‐S and a 2018 ITE score available.
Discussion
In our study, we found a correlation between EM residents’ grit and the ITE score’s prediction of passing the ABEM Qualifying Examination. Since EM ITE scores have been shown to predict future success on the ABEM Qualifying Examination,1, 2 and predicting academic achievement in residents can be difficult,22, 23 Grit‐S scores administered early during training may be useful in helping to predict trainees’ success on the ABEM Qualifying Examination. Our findings corroborate previous studies demonstrating grit’s prediction of educational attainment and success in both nonmedical3, 4, 10, 11, 12, 13 and medical domains.9, 14, 15, 16
While Grit‐S scores may be helpful for medical educators and graduate medical education program leadership to identify residents early on who may perform well academically, our correlation between grit and the ITE’s prediction of success on the ABEM Qualifying Examination was weak to moderate (r = 0.134) and not as strong as we had anticipated. Furthermore, while Grit‐S scores predicted an increase in the ITE’s prediction of success, the increase in percent chance per increase in Grit‐S score was modest (2.30 percentage points). While likely multifactorial, there are likely other noncognitive traits not examined in this study that may have an influence on success on the ITE. For example, the noncognitive trait, self‐control, defined as “the capacity to regulate attention, emotion, and behavior in the presence of temptation,”24 while strongly correlated with grit, has been shown to be more important in the completion of shorter‐term goals, rather than long‐term achievement.3, 4 Residents likely view studying for the ITE as a short‐term goal and therefore, self‐control may have been another predictor of ITE success in addition to grit.
We selected to use the MCAT because it is unique from other medical examinations, including the ITE, in that it does not solely rely on recall of information but also tests analysis and reasoning skills.25 In the initial study of grit by Duckworth et al.,3 researchers used SAT scores as a marker of general mental ability.26 If we consider MCAT percentiles versus other medical tests to be a more similar marker of general mental ability, then the lack of correlation between grit and MCAT percentiles is consistent with the findings of Duckworth et al. findings that grit is not dependent on innate intelligence.3 In fact, grit was found to be negatively correlated with SAT scores,3 suggesting that more intelligent individuals might be slightly less gritty and therefore may not work as hard for achievement.
While not part of our primary objective, we found that while Grit‐S scores did not correlate with the need for remediation, the need for remediation did predict success on the ITE, which would be expected as many residents undergo remediation for low ITE scores. Additionally, USMLE Step 2 CK (Clinical Knowledge) scores have been shown to predict passage of the ABEM Qualifying Examination on the first attempt.27 We did not collect data regarding residents’ USMLE scores in this study so it is possible that there may have been a correlation between grit and Step 2 CK scores that was not assessed in this study.
We also hypothesized that grittier residents might view a low ITE score as a setback and, therefore, persevere to increase their studying and thus be more likely to improve their ITE scores in 1 year compared to residents with lower grit. However, we found no correlation between grit and changes in ITE scores over 1 year. Grittier residents had initial higher ITE scores so they likely were already appropriately preparing and studying for the ITE and thus did not need as much improvement.
Our findings of the stability of EM residents’ Grit‐S scores over a 1‐year period are consistent with previous findings of stability in high school students and general surgery residents.4, 9 This has important implications as the Grit‐S score can be obtained early in training once to help predict success on the ITE throughout residency.
Limitations
There are important limitations to this study. While the multi‐institutional design allowed for a relatively large sample size, it is still a convenience sample. There exists the possibility that residents may have inadvertently self‐reported inaccurate MCAT scores as they were recalling scores from greater than 5 years before. Furthermore, there may have been the potential for self‐bias in survey responses; it is possible that respondents may have filled out the survey in the way they thought they “should,” rather than how they truly felt. In addition, we found a lack of correlation between grit and rates of remediation. Our rate of remediation was 12.5%, which was much higher than the previously reported rate in EM of 4.4%.28 Because of the wide variation in defining remediation across EM programs,29, 30 we used a broad definition for remediation. It is possible that if we had used a stricter, more narrow definition, we may have identified the residents who were at highest risk for struggling academically or professionally or may have identified residents needing further remediation. ITE scores are subject to numerous other influences that were not measured in this study including residents’ personal lives and clinical rotation schedule, Furthermore, residency programs have varying levels of curricula geared toward ITE preparation including review sessions and online question bank assignments that likely influenced residents’ ITE scores at each institution.
Conclusion
We identified a positive correlation between emergency medicine residents’ grit and the likelihood of passing the American Board of Emergency Medicine Qualifying Examination, as measured by the in‐training examination. Although a weak to moderate correlation, the Grit‐S scale may represent a valuable method for early prediction of academic success of emergency medicine residents and may be useful in identifying residents that may require close monitoring and coaching early in their postgraduate training. Our findings add to a deeper understanding of the complexity of resident achievement and also raise the possibility that other noncognitive traits may be worth exploring in the future for predicting success in residency.
The authors thank Stephen Hall for his support with the statistical analysis.
Supporting information
Data Supplement S1. Short Grit Scale.
Presented at the Council of Residency Directors’ Annual Meeting, Seattle, WA, March 2019.
The authors have no relevant financial information or potential conflicts to disclose.
Author contributions: All authors meet all four criteria for authorship per ICJME. ASO, KW, NH, NC, and NO conceived and designed the study; ASO, KW, NH, NC, and NO conducted the study and acquired the data; ASO and NO analyzed and interpreted the data; ASO, KW, NH, NC, and NO drafted the manuscript; and all authors contributed substantially to revising the manuscript critically for important intellectual content, provided their final approval of the version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors are members of the Emergency Medicine Education Research Alliance (EMERA).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Supplement S1. Short Grit Scale.