Resident Behaviours to Prioritize According to Canadian Plastic Surgeons

Abstract

Introduction:

Many articles have been published outlining the resident selection process for plastic surgery training programs. However, which qualities Canadian plastic surgeons value most in their current residents remains unclear. A national survey study was conducted to identify which attributes surgeons associate with the highest resident performance and which behaviours trainees should prioritize during their training.

Methods:

A literature review was performed to identify studies that documented attributes valued in plastic surgery applicants and characteristics of high-performing surgical residents. These qualities were extracted to construct a survey consisting of both ranking and open-ended questions. After an iterative review process, the survey was disseminated nationally to consultants and trainees of Canadian plastic surgery training programs.

Results:

Survey responses were obtained from 120 invitees and a weighted rank was calculated for each evaluated attribute. The terms integrity, professional, and work ethic were viewed as the most important attributes prized by surgeons. Dishonesty, lack of dependability, and unprofessionalism were viewed as the most concerning behaviours. Additionally, disinterest and arrogance were identified by the open-ended questions as behaviours surgeons would like to see less frequently in their trainees. When compared to surgeons, trainees undervalued the importance of knowledge and the impact of unprofessional behaviour.

Conclusions:

With the multiple roles that a resident must fulfill, understanding which attributes are of the most importance will help focus self-directed learning and development within residency programs. Ultimately, instilling the importance of integrity and professionalism is most highly valued by members of the Canadian plastic surgery community.

Introduction

The selection of residents has long been a challenging endeavour for surgical programs.^1,2 Plastic surgery programs in particular are faced with the daunting task of selecting top applicants from large pools of competitive and accomplished medical students to fill only a few new positions each year.³ In an attempt to increase transparency and move toward a standardized application practice, detailed selection criteria used by plastic surgery training programs have become increasingly available within the medical literature.^1,4

In an effort to improve plastic surgery resident selection to better reflect the values of the greater plastic surgery community, multiple survey studies have been conducted to identify surgeons’ perceptions of the ideal surgical applicants.^4-6 Liang et al⁵ previously polled members of the American Association of Plastic Surgeons to determine which characteristics they prized most in plastic surgery applicants. Their findings provided a framework to help guide the resident selection process at American plastic surgery training institutions, which annually accepts more than 100 new positions into the integrated plastic surgery stream. Unlike the United States, there are currently only 12 plastic surgery training programs in Canada that account to approximately 20 new residency positions for Canadian medical graduates annually.⁷ Canadian medical students do not receive grades or other objective indicators of their performance and do not complete the United States Medical Licensing Exam (USMLE) part 1 as a requirement of their training. Therefore, training programs almost exclusively rely on subjective elements for resident selection, including rotation reviews and reference letters.¹ Additionally, as trainees’ transition into residency, their increased responsibilities and service opportunities may result in a shift in the expectations placed upon them. It is important to identify the differences between successful medical student applicants for plastic surgery training and effective plastic surgery residents to determine the qualities specific to each role and which qualities should be prioritized as a resident. In order to better demonstrate which subjective characteristics are most valued by the plastic surgeons within their residents, we constructed a survey-based study which was disseminated to the Canadian plastic surgery community. This information will ideally be of value to both training institutions for future resident selection and residents to direct their own self development. With the future of Canadian plastic surgery training transitioning to the competency by design model, it is essential for trainees to comprehend how to prioritize their self-development during their limited training years.

Methods

Literature Review

For survey development, the literature was reviewed to identify characteristics that were associated with positive or negative performance during medical training. Identified studies met the inclusion criteria if they (1) detailed characteristics that are selected for in surgical residents by training programs or (2) detailed characteristics correlated with metrics of success during residency education. Studies were excluded if they were (1) unavailable in English or (2) focused on trainees outside the field of medicine. No restrictions for primary review were made based on publication. The review was conducted using a single search engine, PubMed (1948-2017) using the search terms “surgical resident,” “resident,” “student,” “attributes,” “characteristics,” “residency,” “success,” “remediation,” and “medical education” in January 2017. The specific search strategy is available in Supplemental 1. Search results were screened by title and abstract. Then, candidate studies were subjected to a secondary review of their full texts for relevancy and to ensure that selected studies discussed resident characteristics and attributes associated with surgical training. The reference lists of these studies were also reviewed for potentially relevant articles. A final list of studies was then subcategorized based on their study population (medical students or residents) and if they discussed performance characteristics that associated with success during training or remediation. A total of 17 studies that focused on positive characteristics of medical trainees (applicants and residents) and 4 studies focused on negative characteristics of medical trainees were identified.^1-6,8-22

Survey Composition

The survey was constructed through an iterative process as outlined by best practice literature.^23-26 Using our literature search results, we identified relevant terms associated with resident performance. These terms were then organized into a series of ranked questions followed by a survey pilot trial with a period of feedback review. After modification and improvement, the survey was then disseminated.

The studies identified from the previous literature review were analysed for specific key terms that described qualities associated with trainee performance, such as leadership, maturity, and knowledge. A list of terms was extracted from this review that were supported as being either desirable or undesirable, consisting of a total of 33 positive terms and 46 negative terms. As the scope of the reviewed studies was heterogeneous, multiple inclusion criteria were constructed to facilitate the extraction process. Terms were incorporated into the initial list if they were (1) associated with specific characteristics valued by program directors, (2) correlated with resident performance by either subjective or objective analyses, or (3) supported by expert opinion with a justification of their importance for residency training. Duplicate terms were removed. Terms with similar definitions were consolidated into a single term. The final list of relevant attributes included 16 positive and 18 negative terms. Both positive and negative terms were included within the survey to provide the opportunity to identify consistency in respondent values and account for variation between the ranked questions. Definitions for each term were written based on their original use obtained from their source studies and constructed to be congruent with CanMeds published principles.²⁷

Using the term list, a draft survey was constructed by organizing all terms into 2 forced ranking questions. Forced ranking questions were chosen as it was hypothesized that Likert or scale-based questions would not enforce the ability to create a tiered priority list if all terms were weighted as being equally important. This survey was then subjected to a pilot trial that was disseminated to a small group of 15 lay people for appraisal of readability and clarity. Respondents noted the rank term lists to be encumbering and redundant. This prompted the ranking questions to be further condensed into 10 terms each. Additionally, 3 open-ended text questions were added to provide respondents the opportunity to expand on the ability to highlight valued attributes beyond the ranked term lists (Table 1). The definitions of the 10 positive and 10 negative terms were included within the survey for reference and to ensure standardization of survey respondents understanding of the terms. The ranked questions were presented first, followed by the open-ended questions, to ensure clarity and organization within the survey structure.

Table 1.

Resident Attributes Selected for Survey-Based Ranking.^a

Positive Terms	Negative Terms
Teacher	Inefficiency
Efficiency	Poor technical abilities
Self-directed learning	Poor communicator
Communicator	Poor knowledge
Technical abilities	Limited self-improvement
Knowledge	Inability to work as a team
Works well with others	Unprofessional
Professional	Disinterested
Worth ethic	Lack of dependability
Integrity	Dishonesty

^a A list of both positive and negative terms was extracted from the literature from studies identifying traits associated with successful resident performance. These terms were edited for duplicates and synonyms. A list of 16 positive and 18 negative terms were incorporated into a pilot survey and then reduced to 10 positive and 10 negative terms based on reviewer feedback. These terms were defined and incorporated into the final disseminated survey.

The final survey was then disseminated by e-mail to all plastic surgery consultants, fellows, and residents affiliated with the 12 plastic surgery training programs in Canada. Informed consent to participate in the study was outlined in the survey cover letter and provided by completion of the questionnaire. Responses were collected after a 3-month period and subjected to descriptive analysis. Descriptive statistics including weighted averages, mean ranks, and standard deviations were calculated for each positive and negative term from the pooled responses. The responses from the 3 open-ended questions were reviewed by a single author (P.M.) for common themes. These identified themes were then ranked based on their frequency and compared against the responses obtained from the closed ranking questions to identified consistency between question type.

Results

A total of 120 survey responses were obtained (17% response rate). Of these, 86% were plastic surgeons, with the remaining 14% being accounted for by fellows and residents (grouped as trainees). Responses were obtained from all Canadian training institutions with the exception of the University of Laval.

Results From the Forced Ranking Attribute Questions

A weighted average, mean rank, and standard deviation were calculated for each term from the survey ranking questions. When respondents were asked to rank the positives terms, the terms “integrity,” “work ethic,” and “professional” scored the highest as the most important (mean ranks of 2.99 ± 2.39, 3.11 ± 2.63, and 4.62 ± 2.16, respectively, Figure 1). The terms that scored the lowest were “self-directed learning,” “efficiency,” and “teacher” (6.88 ± 2.25, 6.87 ± 2.14, and 9.09 ± 1.66, respectively). When respondents were asked to rank the negative terms, the terms “dishonesty,” “lack of dependability,” and “disinterested” scored the highest as the most concerning terms (1.47 ± 1.35, 3.79 ± 2.06, and 4.22 ± 2.1, respectively, Figure 2). The negative terms “poor communicator,” “poor technical abilities,” and “inefficiency” scored the lowest, with mean ranks of 7.18 ± 1.9, 7.32 ± 2.3, and 8.1 ± 2.08, respectively. The mean rank positions and standard deviation for each team are summarized in Figures 1 and 2 for positive and negative terms, respectively. The majority of both positive and negative terms had a standard deviation of approximately 2, indicating that most terms had a variability of approximately 2 positions within the rank list between respondents.

Figure 1.

Positive resident attributes ranked by importance within the plastic surgery training community. Survey responders ranked a list of 10 terms from most to least priority. A mean rank position was calculated for each term based on the ranked positions obtained from each survey respondent, with a higher average indicating a term of greater importance. Error bars depict the standard deviation for each mean rank position.

Figure 2.

Negative resident attributes ranked by importance within the plastic surgery training community. Survey responders ranked a list of 10 terms from most to least concerning. A mean ranked position was calculated for each term based on the ranked positions obtained from each survey respondent, with a higher average indicating a term of greater negativity. Error bars depict the standard deviation for each mean rank position.

The survey responses were then stratified by respondent’s level of training as either consultants or current plastic surgery trainees to compare differences between educators and students’ perceptions on the qualities of an ideal resident. The consultant’s positive term rankings were found to be the same as the non-stratified results. Consultants listed the most important positive terms to be “integrity,” “work ethic,” and “professional” and the least important positive terms to be “self-directed learning,” “efficiency,” and “teacher.” The rank order produced by the trainee subgroup, however, resulted in a priority list that was markedly different from the consultants and non-stratified results. Only the positive terms “work ethic” (second most important) and “teacher” (tenth most important) were placed in the same position by trainees as by the consultants. Trainees valued the positive attributes of “work ethic,” “works well with others,” and “integrity” the most and deemed the least important positive attributes to be “teacher,” “self-directed learning,” and “knowledge.” Between consultants and trainees, individual terms differed by up to a maximum of 3 rank portions. The terms with the largest discrepancy between consultants and trainees were “works well with others,” “knowledge,” and “efficiency” all of which differed between the 2 groups by 3 positions (Figure 3).

Figure 3.

Plastic surgery consultant and trainee comparison of positive resident attributes ranked by importance. From the survey respondents, resident attributes were ranked by order of importance by plastic surgery consultants and trainees. Differences in rank position for each term between trainees and consultants is visually displayed by discrepancies between the 2 lines.

When asked to rank negative resident qualities, both consultants and residents produced a rank list that was different from the non-stratified results shown in Figure 2. Consultants listed the most concerning negative terms to be “dishonesty,” “unprofessional,” and “lack of dependability,” whereas the least concerning negative terms to be “poor technical skills” and “poor communication inefficiency.” In contrast, trainees ranked “dishonesty,” “lack of dependability,” and “inability to work as a team” as most concerning, while “poor technical abilities,” “poor knowledge,” and “inefficiency” were labelled as least concerning. Unlike the positive attributes, discrepancy in the rank position of the negative attributes was seen to a lesser degree between consultants and trainees. For the majority of the negative terms, consultants and trainees produced a similar priority list with the individual term rankings falling within 2 ranks of each other. Only the term “unprofessional” was disagreed upon by 3 rank positions between the 2 subgroups (Figure 4).

Figure 4.

Plastic surgery consultant and trainee comparison of negative resident attributes ranked by importance. From the survey respondents, resident attributes were ranked by order of importance by plastic surgery consultants and trainees. Differences in rank position for each term between trainees and consultants is visually displayed by discrepancies between the 2 lines.

Results From the Open-Ended Behavioural Questions

Three open-ended questions were included within the survey following the 2 attribute ranking questions. The responders were asked which characteristics they believed were associated with being an ideal surgical resident. They were also asked which behaviours they wanted to see less often, and which behaviours they wanted to see more often when working with surgical residents. The written responses for these questions were qualitatively reviewed for representation of common themes. Approximately 20 unique themes were identified from each of the open-ended questions. These themes were then organized by frequency and the most frequently identified themes from each question being presented in Figure 4.

The results of the open-ended questions reinforced the most important positive attributes identified by the ranking questions including the need for residents to display a superior work ethic, to be trustworthy, and to display integrity to be of utmost importance for a successful surgical resident. Displaying a positive attitude and expressing interest in their surgical training was also prized as a behaviour valued by members of the plastic surgery community.

The open-ended responses produced multiple negatively viewed behaviours that were not accounted for in the forced ranked questions. Respondents expressed concerns with resident behaviours such as complaining, work avoidance, and arrogance, which they wished to see less frequently. Additionally, behaviours that they hoped residents would demonstrate more frequently included supporting their colleagues, showing initiative, and maximizing their learning opportunities by preparing around surgical cases. These open-ended questions suggest improvements in resident attributes and relationship with their colleagues should be optimized (Figure 4).

Discussion

There is currently a limited amount of information available on the perceptions of plastic surgery residents and their performance once accepted into a training program. This survey study presents the attitudes expressed by surgeons involved in training plastic surgery residents and the behaviours that they hope to instill or observe within their trainees.

Using both forced ranking and open-ended questions, the attributes found to be most valued by the Canadian plastic surgery community were integrity and work ethic. These terms were ranked highly among both surgical trainees and consultants. Within the survey, integrity was defined as demonstrating honesty and the highest ethical standards in all professional activities. The importance of integrity has been previously highlighted by an American study, suggesting a similarity in the perceptions of an ideal resident across North American training institutions.⁵ Similarly, a survey-based study of American plastic surgeons also concluded that honesty was the most prized positive attribute in resident trainees followed by work ethic.⁵ Additionally, when LaGrasso et al³ surveyed a population of previous plastic surgery program directors, they found the subjective traits of integrity and hard work to be important qualifications for residency training. The consistency in these findings reinforces the intense nature of residency training that requires residents to display a strong commitment to their training and learning opportunities. Furthermore, integrity being viewed as the most important attribute may reflect the current structure of resident training. Consultant plastic surgeons must be able to maintain trust and expect honesty from their trainees in order to ensure that resident training does not compromise the safety of either patients or other health-care providers.

Unlike previous studies, professionalism was incorporated into our survey to gain an appreciation of its importance within training programs. The Royal College of Physicians and Surgeons of Canada outlines professionalism as a core competency that is required of physicians to fulfill their role within the Canadian health-care system. They define a professional as a physician committed to the highest ethical standards, to display accountability and commitment to their patients.²⁷ Integrity is an essential component of professionalism; therefore, it is not surprising that this broader term is an expected behaviour from surgical trainees and is highly endorsed by academic plastic surgeons. A high ranking of professionalism demonstrates that the foremost important qualities for a surgical resident selection are aligned with the core characteristics of any physician.²⁸ Furthermore, professionalism’s emphasis on maintaining high ethical standards reinforces the idea that a commitment to avoiding participation in activities that would decrease the public’s trust is of the highest value within the medical community. Finally, the need for professional behaviour is reflected by the fact that academic plastic surgeons must be able to rely on their residents to respectfully represent their training institution, given that they are not being directly observed at all times.

Technical abilities, teaching capacity, and efficacy were not as highly ranked of the attributes valued in resident trainees. The structure of our survey using forced ranked questions innately results in producing a set of term of lowest importance even when all options are still of importance. While there is no doubt that these traits are of value, it is possible that they are not required for the initiation of surgical training and residents may instead develop these skills during their training. Technical abilities would be assumed to be of value in a surgical environment. In contrast, previous work by Hillis et al²⁹ conducted a similar survey-based study and found technical studies to be of utmost importance in the general surgery community. Their survey was completed by primarily residents, which may more strongly represent the resident’s goals as opposed to the qualities valued by consultants. Additionally, this discrepancy may reflect the belief that technical skills can be acquired by almost all residents within plastic surgery and is therefore expected rather than prioritized.³⁰

The results of the 2 ranking questions were also stratified by academic role (consultants or trainees) to identify differences in perceptions of resident performance between these 2 groups. The goal of this comparison was to determine which attributes that residents were either over- or undervaluing relative to consultant’s priority of the listed qualities. By examining this disconnect between the staff and resident appreciation of the characteristics of the ideal trainee, we can appreciate that trainees overvalued working well with others and efficiency while undervaluing knowledge. Trainees ranked working well with others as the most important positive term, but consultants ranked the term as fourth most important. From the results of the open-ended questions, it is clear that consultants value the importance of working within a team dynamic and desired resident to increase their support of their peers. However, the overall term ranking suggests resident’s emphasizing on teamwork should not take precedence over the core components of being a model surgeon: professional, hardworking, and displaying integrity.

The negative terms of most concern to the plastic surgeons unsurprisingly parallel similar core values introduced by the positive term ranked list. Dishonesty and lack of dependability are profoundly negative qualities of trainees that both staff and residents consistently identified as being of concern. Additionally, both populations rated disinterest as being of particular concern and ranked it highly of the negative attributes. Disinterest can manifest in many ways by surgical residents and it is likely that expressing apathy toward learning opportunities does not invite instructors to invest in resident training. The open-ended questions highlighted additional undesirable qualities of complaining and arrogance as behaviours consultants want to see less often. In conjunction, these findings suggest that plastic surgeons expect their residents to appreciate their learning opportunities and are under impressed when residents demonstrate behaviours which reflect and lack of enthusiasm or fail to appreciate the privilege and responsibility of their training.

Not all negative terms were agreed upon as being equally important between consultants and trainees. Trainees undervalue the impact of being unprofessional. Consultants ranked being unprofessional as the second most concerning negative behaviour after dishonesty. Trainees, however, ranked unprofessional as fifth concerning. This discrepancy likely reflects trainees under appreciating the importance of the physician–patient relationship as being essential to delivering successful health care. Being unprofessional can weaken a patient’s confidence in a physician’s ability to provide care and damage their therapeutic alliance. It is possible that residents view this to be the responsibility of their supervising consultant and therefore undervalue their own responsibility toward curating their relationships with the patients whom they treat.

Understanding surgeons’ values may be of benefit to identifying which medical students would function as the ideal plastic surgery resident. Numerous studies have shown that residents are selected for based on academic excellence, commitment to research, and performance evaluations.^4,6,10 The merits of prospective residents are, therefore, primarily highlighted through scholarship, which is helpful for identifying candidate residents who will become knowledgeable and self-driven. However, integrity and professionalism are difficult to appraise in the current application system. These qualities are more likely to be witnessed during a rotating clinical elective, or potentially from a formal interview. Cullen et al³¹ noted that when a professionalism score was evaluated against the multiple elements of a residency application, only the letters of support correlated with applicant professionalism. They suggest that direct observation is therefore essential to determine candidates who possess these characteristics and that scrutiny of these letters of support is necessary for selecting this attribute.

In order to ensure that future surgical applicants meet the expectations of their mentors, integrating professionalism into the current medical curriculum is of primary interest to plastic surgery community. Although this has been done to varying degrees at the majority of medical schools in a didactic manner, Duff et al³² claimed that modelling appropriate behaviour by instructors is the most effective way to teach professionalism. A survey targeting medical students also supported this and stated that students believed role modelling and pre-medical school values were primary contributors to developing professionalism.³³ Thus, in order to engage with future resident candidate and model the behaviours they desire, plastic surgeons may benefit from making themselves available to develop mentorships with students prior to residency selection. This way, they can recruit prospective residents early enough to evaluate their professional qualities while also educating on behaviours they want to see more of. Apart from clinical rotations, opportunities to establish this surgeon–student contact can occur during small group sessions and half day teaching seminars where intimate classrooms serve as an opportunity for student recruitment and focused surgical education.³⁴

The goal of this survey was to identify the discrepancies between trainees and staff surgeons on their perspectives of ideal resident qualities. This was done using a constructed survey that was designed through iterative process; however, future studies may benefit from pursuing a Delphi-based methodology, which could strengthen the assessment tool being utilized.³⁵ Other potential limitations include the cross-sectional study design, which only offers insight into the values of respondents at the time of survey dissemination. In the future, as plastic surgery training programs transition to a competency by design model, a repeat evaluation of this type may be warranted to determine how this change in the model of training has on surgeons’ perceptions.

Conclusion

In this study, we surveyed the plastic surgery community to identify which characteristics of plastic surgery trainees are of greatest value. Placing value on integrity, work ethic, and an appreciation of for training opportunities demonstrates that plastic surgeons are ultimately looking for qualities that facilitate a functional mentorship. Furthermore, the lower ranked qualities of technical skills, teaching abilities, and efficiency suggest residents will acquire these skills later in residency as they transition into independent practice. Plastic surgery training is now shifting toward competency-based education, which encompasses an increased reliance on parameterizing educational milestones and repeated performance review. In order to maintain the development of successful educational mentorships within training programs, program directors will ultimately be faced with developing increased scrutiny toward the attitudes and behaviours of surgical applicants.

Figure 5.

Responses with highest representation obtained from the open-ended questions about resident behaviours. Three questions were included within the survey providing respondents with the ability to explain on behaviours they would like to see residents do more often, do less often, and behaviours to start doing. These responses were grouped by comment themes and the 4 most common themes from each question represented within the graph.