To the Editor: Professionalism in Residency Feedback

A slew of negative reviews, mostly in the form of complaints on the emergency medicine (EM) monthly rotation evaluations, has been an early warning sign to us that our residency culture is threatened. A culture of complaining poses not only an immediate risk to the work environment of the emergency department, but also a longer-range risk to the development and application of the Accreditation Council for Graduate Medical Education (ACGME) core competency and subsequent subcompetencies in professionalism. As a soon-to-be graduating resident who will be pursuing a fellowship in administration in similar teaching hospitals, and a current core faculty member in EM, the topics of culture and how culture change can influence the acquisition of the ACGME core competencies in medical training are of keen interest to us. Therefore, we found the article by Seehusen, “Understanding Unprofessionalism in Residents,” to be highly relevant to this quandary.¹

Seehusen provides 3 main questions to guide a program toward the underlying cause of a fallout in professionalism. The question most salient to our situation and most easily answered is: “Does the resident understand professional expectations?” In our case, we are using the overall tone of recent evaluations as guiding feedback that many residents do not understand each component of this expectation, particularly as it refers to the ACGME definitions of professional accountability and continued professional growth. Seehusen reasons that professionalism is a learned skill, so residents “cannot be expected to be fully proficient in professional behaviors.”¹ Therefore, it seems reasonable that to foster a more concrete sense of accountability and professional growth, the question wording on the EM evaluation should be reviewed and modified to encourage more solution-oriented responses.

Although data are sparse, studies do show that changing the wording of questionnaires can result in an overall increase in the number of comments and obtainable action items, as well as a modulatory effect in valence (from negative to positive for example).^2,3 One study even showed that modification in how an evaluation was worded in the context of descriptive systems can lead to positive physical changes in health utility.⁴

The language of an evaluation carries powerful implications, and we believe that changing the wording of our EM rotation evaluation will help to make the professionalism expectations more apparent as suggested by Seehusen, improving evaluation scores, and fundamentally, the EM rotation.