Measuring and Improving Emotional Intelligence in Surgery – A Systematic Review

Mini-Abstract:

This systematic review aims to scope the literature regarding the measurement of emotional intelligence (EI) in surgery. Most studies occurred in residency programs and four studies involved an intervention to assess whether EI improved. EI may be a promising, trainable skill relevant to surgical teamwork and patient-relevant outcomes.

Abstract

Objective:

Evaluate how emotional intelligence (EI) has been measured among surgeons and to investigate interventions implemented for improving EI.

Summary Background:

EI has relevant applications in surgery given its alignment with non-technical skills. In recent years, EI has been measured in a surgical context to evaluate its relationship with measures such as surgeon burnout and the surgeon-patient relationship.

Methods:

A systematic review was conducted by searching MEDLINE, EMBASE, CINAHL, and PSYCINFO databases using PRISMA guidelines. MeSH terms and keywords included “emotional intelligence,” “surgery,” and “surgeon.” Eligible studies included an EI assessment of surgeons, surgical residents, and/or medical students within a surgical context.

Results:

The initial search yielded 4,627 articles. After duplicate removal, 4,435 articles were screened by title and abstract and 49 articles proceeded to a full-text read. Three additional articles were found via hand search. A total of 37 articles were included. Studies varied in surgical specialties, settings, and outcome measurements. Most occurred in general surgery, residency programs, and utilized self-report surveys to estimate EI. Notably, EI improved in all studies utilizing an intervention.

Conclusions:

The literature entailing the intersection between EI and surgery is diverse but still limited. Generally, EI has been demonstrated to be beneficial in terms of overall well-being and job satisfaction while also protecting against burnout. EI skills may provide a promising modifiable target to achieve desirable outcomes for both the surgeon and the patient. Future studies may emphasize the relevance of EI in the context of surgical teamwork.

INTRODUCTION

Current research in surgical patient safety increasingly emphasizes the significance of non-technical skills.^1,2 Emotional intelligence (EI) is a related concept that underpins high performing operating room teams, but cannot be measured by existing non-technical skills assessment tools.³ EI is largely described by Mayer and Salovey as a multi-faceted ability to appropriately convey, identify, understand, and harness both one’s own emotions and those of others.⁴ EI abilities are highly applicable to the surgeon as negative emotional states (e.g. anger or frustration) may impede effective communication, ultimately compromising patient safety and resulting in preventable harm.^1,5,6

Beyond the positive benefits of EI in terms of social relationships⁷ and work performance,⁸ EI has significant implications for surgical teamwork.⁹ A retrospective analysis in the context of an unexpected surgical crisis suggested that the EI of healthcare workers involved, spanning from surgeons to operating room managers, allowed for effective perioperative management and coordinated patient care.¹⁰

Notably, EI may be teachable, such that it can improve when provided with appropriate coaching.¹¹ Other EI related research in healthcare has shown that EI may increase with time as a result of accumulated experience and the attainment of non-technical competencies throughout medical and surgical training.^12,13

Although several forms of EI assessments have been developed to quantify an individual’s EI, many of the current limitations surrounding EI in surgery are in the context of its assessment.¹⁴ Some EI tools require the use of a Likert scale while others require responding correctly to a question.¹⁵ This discussion raises the issue of appropriate classifications of EI: a trait (i.e. within the domain of personality), an ability (which involves a cognitive perspective) or a mixed model which encompasses both personality and ability components.^14,15

Previous reports on EI in surgery have been conducted in the context of surgical education,¹⁶ academic and career achievement,¹⁷ and descriptive evaluation of the importance of EI to surgery.⁵ However, it is unclear as to how EI has been applied in a surgical context at large. This review aims to systematically scope the available literature to investigate the use of EI in surgery and identify the relevant overarching findings. This study also evaluates the various tools used to measure EI and the specific surgical contexts in which these tools have been implemented. Furthermore, we intend to discuss any significant interventions aimed at improving EI in surgery.

METHODS

A systematic review was conducted in August 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.¹⁸ This review is registered with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42020204812). The following databases were searched from inception until August 19^th, 2020: MEDLINE, EMBASE, PSYCINFO (EMBASE), and CINAHL (EBSCO). Search terms involved MeSH terms and keywords and were adapted between databases to be as equivalent as possible. Additionally, citations by texts that passed the full-text screen were hand searched to identify additional studies that may not have been captured by the search strategy. Supplemental Digital Content 1 details an example search strategy used in MEDLINE.

Selection Criteria and Screening Process

We aimed to include studies that were published in peer-reviewed journals. Included studies involved the measurement of EI within a surgical context. The target population included surgeons across all surgical specialties and different training levels (residents, fellows, and attendings). We also included studies that involved medical students participating in surgical tasks, engaging in a surgical setting, or choosing a surgical career. We excluded studies that were not written in English, did not measure EI, review articles, conference abstracts, letters to the editor, incorrect target population, and articles in which surgeon EI was not reported separately (e.g., scores pooled together with non-surgical specialties).

Two authors (J.G.A. and L.K.M.) screened the titles and abstracts to identify articles that would be later assessed by a full-text screen. The title/abstract screen was conducted with the Rayyan QCRI web platform.¹⁹ The same two authors conducted a full text read of included papers independently based on the established inclusion and exclusion criteria. Reasons for exclusion were recorded. Conflicts that arose during either the title/abstract screen and the full-text read were resolved with written specific justification for inclusion or exclusion based on eligibility criteria. If not resolved, a third author would make the final decision. If an article passed the full text screen, specific data were extracted using pre-determined data columns. Data extraction was conducted by one author (J.G.A.) after doing a calibration test with the second author (L.K.M.). This calibration test was based on three included studies to ensure agreement between the two reviewers. The second author was consulted for articles that may have been either unclear or did not appropriately fit the pre-determined outcomes of interest. Figure 1 illustrates the PRISMA flow diagram detailing the number of articles that were screened and ultimately included.

Figure 1:

PRISMA flow diagram demonstrating the screening process.

Data synthesis and quality assessment

A narrative synthesis of quantitative data²⁰ was conducted to identify themes in how EI has been applied in the surgical context. Variables of interest that were extracted included the types of participants in the studies, the surgical specialty (if specified), study design and context, EI assessment tool, and other measures evaluated in conjunction with EI. A quality assessment was performed independently of data extraction using the Medical Education Research Study Quality Instrument (MERSQI)²¹ which involves the evaluation of a study’s design, sampling, data type, validity of assessments, data analysis, and outcomes. A study may achieve a MERSQI score between 5-18 with higher scores indicating higher quality studies (such as a randomized control and objective assessments of participants). The reported MERSQI score was calculated by one author (J.G.A.) after doing a calibration test with the second author (L.K.M) based on three included studies in order to establish agreement in assigning quality assessment scores. MERSQI scores in the calibration test were conducted on separate Excel sheets and checked for matching values after completion.

RESULTS

Our search retrieved 4,627 articles over four different databases. After 192 duplicates were removed, 4,435 articles were screened by title and abstract. 49 articles were assessed with a full text read and an additional three articles were found through a citation hand search. A total of 52 papers underwent a full text read. 37 met our eligibility criteria and underwent the data extraction and quality assessment processes. A narrative synthesis of quantitative data²⁰ was subsequently conducted (see Supplemental Digital Content 2).^{22–31,32–37,38–42,43–52,53–58}

EI Tools

Within all 37 studies, there were 41 instances of an EI assessment tool being used. The majority (n=14/37, 37.8%) utilized the Trait Emotional Intelligence Questionnaire (short form). There were four studies (10.8%)^35,39,43,44 that employed the long form of the Trait Emotional Intelligence Questionnaire. Eight studies (21.6%)^{26,29,31,36,37,51,52,55} utilized a version of the Bar-On Emotional Quotient Inventory and four studies (10.8%)^26,27,30,38 utilized a version of the Mayer-Salovey-Caruso Emotional Intelligence Test. Additionally, there were two studies (5.4%)^46,56 that assessed EI using the Emotional Quotient Appraisal Survey and two studies (5.4%)^57,58 utilized the Wong and Law Emotional Intelligence Scale (WLEIS). There was one study (2.7%)³⁹ in which the Trait Emotional Intelligence 360-form (short version) was used. Lastly, there were six studies (16.2%)^{24,26,34,36,48,50} that utilized a different EI assessment. These other assessments include the Scale of Emotional Functioning – Health Service Provider, Trait Meta-Mood Scale, a construct of the Goleman Emotional Intelligence index, the Emotional Intelligence Scale – Faces, the Energy Leadership Index providing an Average Resonating Level, and the Workplace Emotional Intelligence Checklist (see Supplemental Digital Content 3).

Percentages exceed 100% because there were three studies (n=3/37, 8.1%)^26,36,39 that reported on the use of more than one type of EI assessment. One study³⁶ utilized two EI tools by having participants complete the Bar-On Emotional Quotient Inventory and answer questions related to the Goleman EI construct. Another used both the long form of the Trait Emotional Intelligence Questionnaire and the short version of the Trait Emotional Intelligence 360-form. Additionally, one study²⁶ reported on the results from three institutions, each using different EI tools (the Mayer-Salovey-Caruso Emotional Intelligence Test, the Bar-On Emotional Quotient Inventory, and the Trait Meta-Mood Scale) (see Supplemental Digital Content 3).

Of the 37 studies, 33 (89.1%) relied on self-reported EI assessments by either answering a survey, answering questions correctly, or assessing the emotions of various facial expressions. There were two studies (5.4%)^34,57 which incorporated observer EI ratings.

Lastly, there were two (5.4%) studies^39,58 which incorporated both self-reported and observer EI ratings. One of these studies⁵⁸ had participants and raters utilize the Wong and Law Emotional Intelligence Scale. The other study³⁹ had participants complete the long form of the Trait Emotional Intelligence Questionnaire while raters evaluated participants using the short version of the Trait Emotional Intelligence Questionnaire 360-form. Supplemental Digital Content 4 highlights select EI assessments that were utilized throughout the studies included in this review.^59,60

Participants and Surgical Specialties

There was a total of 1,675 unique study participants across included studies. Residents made up the majority of the sample (n=1,010/1,675, 60.3%). Medical students comprised 21.2% (n=355/1,675) of the sample while attending surgeons comprised 18.5% (n=310/1,675). One study⁵² assessed surgeons with active membership in the Royal College in the United Kingdom. For standardization purposes, we classified this group as residents. Most (n=25/37, 67.6%) studies included measured the EI of resident surgeons. There were six studies (n=6/37, 16.2%)^{23,26,34,39,48,55} assessing medical student EI and four studies (n=4/37, 10.8%)^51,56–58 investigating attending surgeons. There were two studies (n=2/37, 5.4%)^29,46 assessing a mixed population; one of which involved both residents and faculty²⁹ while the other involved medical students, residents, and attending surgeons (see Supplemental Digital Content 3).⁴⁶

Within all 37 studies, there were 38 mentions of different surgical fields. The majority (n=18/37, 48.6%) of studies were conducted in general surgery. There were three studies (8.1%)^34,37,46 relevant for obstetrics and gynecology, two (5.4%)^29,47 for otorhinolaryngology, and one (2.7%) each for ophthalmology,³¹ orthopedics,²⁷ and plastic surgery.²⁵ Ten studies (27%)^{22,23,26,31,45,48,52,53,57,58} did not specify the surgical specialty while two studies (5.4%)^51,56 involved a variety of surgical specialties. One study reported on ophthalmology and surgery (not specified) as two different surgical specialties (see Supplemental Digital Content 3).³¹

Study Designs and Settings

Within the studies included, 10.8% (n=4/37) utilized an interventional approach aimed at improving EI.^29,34,50,55 Of these interventions, one²⁹ assessed EI at multiple time points and three studies^34,50,55 assessed EI in a pre-test and post-test manner. There were 33 studies (89.2%) that were observational and utilized an EI survey. Three studies^24,33,42 measured EI at multiple time points whereas 30 studies assessed EI at one time point (see Supplemental Digital Content 3).

In terms of the study setting, 23 studies (62.2%) took place at the level of a residency program or clerkship rotation; three studies (8.1%)^23,45,55 occurred in a primarily simulation setting; three studies (8.1%)^51,57,58 occurred in a hospital setting; two studies (5.4%) each occurred in a medical school setting^26,48 and surgery department^46,56; and one (2.7%)⁵² setting was not specified. Additionally, there were three studies (8.1%)^29,38,54 in which the settings occurred in a multitude of settings. One of these combination settings involved both a department and simulation context²⁹ while the remaining two studies occurred in both a residency program and simulation context (see Supplemental Digital Content 3).^38,54

Comparisons and Other Measures

In some of the included studies, the primary aims involved making comparisons between EI and other participant characteristics. There were nine studies (24.3%)^{22,26,31,44,48,51–53,57} in which EI was assessed in terms of specialty differences to differentiate between surgeons and other types of physicians or identify differences between medical students interested in surgery and those interested in other specialties. Two studies (5.4%)^37,56 involved an EI analysis between participants with and without leadership positions. There was one study (2.7%)⁴³ whose primary aim was to assess gender differences in EI and another study (2.7%)³⁹ in which EI was assessed in the context of applicants to a general surgery residency program.

The articles included in this review also often involved other assessments of participants in addition to EI. Nine studies (24.3%),^{24,25,28,32,33,40,42,50,53} included a measure of burnout. Six studies (16.2%)^{23,40,41,50,51,53} included psychological measures such as depression, well-being, perceived stress, anxiety, and anger. There were also six studies (16.2%)^{26,30,42,46,47,58} that assessed personality or individual features, such as the 10-Item Personality Inventory, Jefferson Scale of Physician Empathy, and Learner Autonomy Profile. Five studies (13.5%)^{25,32,33,35,42} utilized job or career assessments, such as career satisfaction or the Job Resources Questionnaire. Another five studies (13.5%)^{30,38,45,54,56} examined some measure of performance (both technical and non-technical). In terms of objective measures, there were four studies (10.8%)^28,30,35,39 that included the use of test scores, such as the USMLE, ABSITE, or Situational Judgment Test scores in addition to one (2.7%)²³ utilizing heart rate. Furthermore, there were three studies (8.1%)^28,35,47 utilizing surgical milestones or competencies. One study (2.7%)³⁹ examined medical school relevant assessments (such as clerkship grades and interview scores). Lastly, 36 (97.3%) studies assessed demographics of the participants in some form (such as age, gender, or training level). Supplemental Digital Content 3 provides a summary of these findings. All studies taken together scored an average of 0.97 with a standard deviation of 0.64 and a range from 0 to 3 on the validity domain of the MERSQI quality assessment form. The MERSQI validity domain assigns a study a score of 0 to 3 based on whether there are reported statistics for internal validity, content validity, and relationships with other variables.²¹

EI Interventions and Tasks

There were a total of six studies (16.2%) that involved the use of a simulation task: two of which involved breaking bad news to family members of a patient;^38,54 two involving the use of a simulated laparoscopic task;^23,45 one involving various simulated surgical tasks;⁵⁵ and one combining many simulated tasks (including breaking bad news and intensive surgical skill scenarios).²⁹

In the studies involving resident performance of breaking bad news, only one study found that the emotionality factor of trait EI correlated significantly with resident performance in communicating with the standardized patient.⁵⁴ However Lim³⁸ did demonstrate that individuals with higher EI scores were more likely to engage in certain communication behaviors such as minimal use of advanced medical terms and discussing information in smaller amounts. Table 1 provides a comparison of both studies.

Table 1:

Comparative studies involving a breaking bad news simulation

Task	Author (Year)	EI Tool	Breaking Bad News Performance Tool	Performance Raters	Study Design (MERSQI score)*	Overall EI or EI factor correlated with breaking bad news performance scores?
Breaking Bad News Simulation	Lim (2019)38	MSCEIT V2	DBN Checklist	Surgeon and PhD faculty members	Single group cross-sectional (1)	No
	Trickey (2016)54	Trait EIQ – SF	CAT	Standardized Patient	Single group cross-sectional (1)	Yes – emotionality factor of trait EI positively correlated with performance.

CAT = Communication Assessment Tool; DBN Checklist = Delivering Bad News Checklist; MERSQI = Medical Education Research Quality Instrument; MSCEIT V2= Mayer-Salovey-Caruso Emotional Intelligence Test Version 2; Trait EIQ – SF = Trait Emotional Intelligence Questionnaire – Short Form.

^*MERSQI score for study designs range from a minimum score of 1 to a maximum score of 3. Scores of 1 indicate that the study design involved either single group cross-sectional design or a single group post-test design. Scores of 3 are given to randomized control trials.

Regarding the studies which utilized a simulated laparoscopic task, both found significant relationships between EI scores and outcome measurements. For instance, Arora and colleagues demonstrated a significant positive correlation between overall EI scores and post-task stress recovery. Nayar and colleagues⁴⁵ demonstrated that while there was no difference in task performance between residents categorized as having low or high EI scores, residents with high EI exhibited a significant positive correlation between self-assessment and expert assessment of their performance.

Additionally, four (10.8%) studies reported the use of interventions: One occurred in the context of a surgery department and simulation involving both residents and faculty²⁹ while another intervention involved solely residents in a residency program.⁵⁰ The remaining interventions were focused on medical students: one of which involved simulation⁵⁵ and the other taking place in clerkship.³⁴ In all four studies, there was a reported increase in EI for participants (see Supplemental Digital Content 5 for a detailed description of each intervention).

The EI intervention implemented in an otorhinolaryngology department involved the participation of both residents and attending faculty members to engage in EI simulation training exercises.²⁹ EI was assessed throughout the intervention in conjunction with patient satisfaction scores.²⁹ The study reported that participants felt engaged and could incorporate what they learned into their work.²⁹ EI was also found to improve after the training sessions and these gains were maintained throughout the intervention. Furthermore, the resulting increase in patient satisfaction scores was accredited to the department’s elevated EI.²⁹

Another intervention in a general surgery residency program assessed EI in the context of aiming to improve several aspects of resident well-being, leadership skills, and resiliency.⁵⁰ This intervention found an increase in EI as assessed by the Average Resonating Level (ARL) score (as part of the Energy Leadership Index). Other psychological assessments were also conducted and the ARL was found to negatively correlate with perceived stress and depression.⁵⁰

The interventions involving medical students also showed an increase in EI by the end of the intervention. The study conducted by Guseh and colleagues³⁴ had medical students randomized to resident mentors. Some of these residents received additional training in workplace EI, which involved understanding the role of the student within the clinical environment.³⁴ Medical students’ behaviors were then rated by qualified evaluators (e.g. faculty or residents) based on the workplace EI checklist. This checklist uses a Likert scale to rate proactive and adaptable behaviors relevant to the clinical setting.³⁴

One interventional study took place in the context of a simulation intervention geared towards military medical students.⁵⁵ The intervention itself involved trauma simulations (e.g., gunshots, explosions, and combatants) and students also learned procedural skills. All students were found to have an increase in both overall EI and in each of the five EI factors as described by the Bar-On model.⁵⁵

Patient Outcomes

There were three studies (8.1%)^29,57,58 that assessed patient outcomes in some capacity. Two studies focused on patient satisfaction while one focused on patient trust. In all three studies, there was an associated positive outcome when relating the surgeon’s EI and patient outcomes.

Dugan and colleagues²⁹ implemented an EI training intervention for all members of an otorhinolaryngology department and found that patient satisfaction increased in concordance with EI scores. In another study, Weng and colleagues found that surgeons with higher EI have a higher quality patient-doctor relationship.⁵⁸ This was incorporated into a model in which higher quality patient-doctor relationships predicted increased patient satisfaction. Furthermore, surgeon EI correlated positively with patient satisfaction at the initial visit.⁵⁸ The other patient outcome study by Weng and colleagues⁵⁷ assessed differences in EI between surgeons and internists and whether EI correlated with patient trust. There were no differences in EI between surgeons and internists, however surgeon EI correlated positively with patient trust.⁵⁷

Study Quality

The MERSQI scores of all included studies included averaged 10.1 with a standard deviation of 1.9. Scores ranged from 7 to 14.5, with higher scores representing more rigorous studies (such studies would employ pre-test and post-test measures, report internal and content validity, and measure patient relevant outcomes). MERSQI scores may be found for each corresponding study in Supplemental Digital Content 2.

DISCUSSION

In this systematic review, we aimed to present a comprehensive picture of the available research on the use of EI assessments in surgery. The literature demonstrates that EI has been largely assessed in the context of general surgery residency programs with participants providing a self-reported EI via surveys. Its use has varied from comparisons between surgeons and other specialists to the assessment of its relationship with other variables such as burnout. Despite its wide use, the literature is still limited and EI interventions that have been applied in surgery notably lack standardization.

By and large, EI was assessed with self-reported results from the Trait EI questionnaire, which reflects personality and typical behavior (trait model).¹⁵ Other studies utilized mixed model assessments (Bar-On Emotional Quotient Inventory) or ability based measurements (Mayer-Salovey-Caruso EI Test). However it is unlikely that direct comparisons may be made across studies using different EI assessments, as each assessment represents a different EI model.⁶¹ For instance, two studies addressing the relationship between EI and performance in a breaking bad news simulation reported conflicting findings.^38,54 Each study relied on differing EI assessments and performance evaluation tools (see Table 1). Different EI models have been shown to represent separate constructs so it is unlikely that these various EI assessments will yield similar findings.⁶¹ With regards to the evaluation of EI in the surgical context, comparisons should be focused on assessments reflecting the same model in order to draw meaningful conclusions.

Additionally, there remains a limitation to the use of self-report assessments as individuals with lower levels of insight may not provide an accurate view of their abilities and traits.¹⁵ For instance, two studies employing both self-reported and observer-reported EI found no significant agreement between raters.^39,58 Therefore, the use of both self-report and rater observations may mitigate this limitation.^5,62 Observer ratings would require the use of a 360-degree form which has been proposed as a tool to target and improve EI skills via structured feedback.⁶² In one retrospective study examining the 360-degree feedback of coworkers evaluating orthopedic surgeons, researchers demonstrated that feedback on the 360-form correlated with patient satisfaction.⁶³ The use of EI-relevant 360-degree forms may therefore have implications for facilitating teamwork and enhancing patient outcomes.^62,63

As the pursuit of surgical training is an intense endeavor, EI has been largely examined in the context of residency programs. Although evidence of EI as a predictor of resident performance is mixed,^30,47,64 Lin and colleagues³⁹ found that applicants to a general surgery residency program who were ranked highly tended to have higher EI scores. Residency may also serve as an opportune time to improve EI.^5,50

One possible way to address resident EI is to elevate faculty interest in EI. For instance, a detailed follow-up study to the intervention conducted by Riall and colleagues⁵⁰ highlighted resident preferences for faculty investment in EI interventions.⁶⁵ Attending surgeons have demonstrated proficient levels of EI in various studies so it may be possible to utilize attending EI as a starting point to guide residents.^29,46,56

Faculty involvement and demonstrated leadership in resident education have been found to be beneficial for the resident experience.⁵⁶ For instance, Weis and colleagues⁵⁶ demonstrated that resident evaluations of faculty members correlated with faculty members’ self-reported EI. If surgeons value and practice interpersonal and communication proficiencies inherent to EI, resident perceptions of these factors may reasonably increase.^29,56 For instance, it has been previously shown that a military leader’s EI positively impacted the group’s EI, which in turn, affected group level performance.⁶⁶ The surgeon’s role as a leader may therefore influence workplace culture in a positive manner for colleagues and trainees.^29,66

In the current review, as well as in previous reviews of EI in healthcare, EI scores have been correlated with other measures, particularly psychological measurements such as burnout, depression, and well-being.^5,17 A consistent finding across studies is the inverse relationship between EI and burnout.^{25,32,33,40,42,53} The presence of burnout may have an adverse impact on teamwork in the healthcare setting as one study found that emotional exhaustion predicted poorer teamwork performance in the intensive care unit.⁶⁷ It has been previously demonstrated that burnout mediates the relationship between EI and work performance such that individuals with higher EI experience lower burnout and consequently demonstrate superior work performance.⁶⁸ Future studies may opt to assess EI with validated measures of teamwork in a surgical context to investigate the relationship between an individual’s EI and effectiveness in a team.⁶⁹

Additional research may also assess the role of EI in possibly mitigating the frequency of disruption and incivilities that may occur in surgery.⁷⁰ Although two studies^32,33 found a relationship between burnout and experiencing workplace disruption (e.g., humiliation from attending surgeons), no included study in this review explored the contribution of EI in this capacity. Previous research has demonstrated that higher EI both decreased the likelihood of engaging in inappropriate work behaviors and negatively correlated with workplace incivility.^71,72 In a surgical context, it may be worthwhile to explore the relationship between EI and incivility as workplace disruptions may impact team dynamics and have downstream consequences for patients.⁵

Interventions that were employed across studies differed in regards to execution and overall aims. While one study aimed to monitor patient satisfaction in the context of EI training, other studies examined the development of proactive behaviors, teamwork skills, and resiliency. It should be noted that these interventions may be costly, particularly in the use of simulations and hiring coaches for training.^29,50,55 Although EI improvements through interventions are promising,⁷³ it remains unclear whether there are sustained gains given a general scarcity of longitudinal designs in the surgical context. Prior to implementing any EI-based intervention in a surgical training program, it would be necessary to identify which EI model, and consequently evaluation tools, would be used in order to appropriately tailor the program and monitor EI scores.⁷⁴ For instance, mixed model assessments (i.e. Bar-On EQ-i) comprised half of the interventions presented in this review. Such assessments encompass traits, behaviors, and competencies.¹⁵ As surgical training requires mastering both technical and non-technical competencies, mixed model EI assessments may be more applicable to the surgical context with regards to tracking improvement over time. On the other hand, we anticipate that the use of trait model assessments in EI-focused interventions would not reliably yield similar findings. As the trait model reflects highly stable qualities,^59,61 the effect of interventional programs may either not be captured or an increase in EI would not be maintained over time. Although EI has been shown to be modifiable as a result of targeted interventions,^29,55 it is not immediately justifiable to overhaul surgical training programs and replace the non-technical aspect of a curriculum with a novel program combining various EI models. However it appears that each EI model may have merit to supplement surgical training in order to track desired behavioral or non-technical outcomes within the scope of the specific EI assesssment.^15,50,74

Three studies investigated patient outcomes, all of which attributed a positive impact of surgeon EI on patient outcomes.^29,57,58 As surgeon EI has been implicated in the quality of patient-surgeon relationships, this may ultimately minimize the likelihood of malpractice claims according to a previous review of this literature.^17,58,75 EI has also been implicated in other patient outcomes such as patient safety and compliance with post-operative orders.⁵ By understanding someone’s perspective and being able to manage their emotions, patient compliance for post-operative discharge could theoretically improve.⁵ Overall, evidence suggests that the surgeon’s EI may be applicable to the patient-surgeon relationship and yield both reduced litigation risks and improvement in patient care.

LIMITATIONS

The current limitations of this study largely involve the lower MERSQI scores calculated for the included studies. Most of the studies involved correlational relationships and assessments of perceptions and attitudes. Additional research to strengthen the existing evidence would require assessing behavioral and patient-related outcomes through more rigorous and systematic approaches. In interventional EI studies, authors rarely reported longitudinal follow-up after the cessation of the intervention. In order to determine whether interventions may meaningfully and sustainably improve EI over time, longitudinal follow-up would be necessary. Furthermore, it may be more comprehensive to assess EI using other observant raters in order to minimize bias and control for insight.

CONCLUSIONS

The EI literature in the context of surgery is still under development. By and large, most studies have assessed surgical residents within the setting of their residency programs in order to evaluate relationships between EI and psychological measures such as burnout. Interventions aimed at improving EI have differed in terms of population, scope, and outcomes. However, EI may be a teachable skill with tangible, patient-relevant outcomes and may warrant consideration in the context of development of non-technical skills. Overall, it is critical that surgeons be able to sufficiently manage their emotions when it comes to patient care and safety, especially during high-risk situations. In doing so, an understanding and appreciation of interpersonal dynamics is necessary, alongside effective communication and conflict management skills. Further work is needed to elucidate the contribution of EI in surgical teamwork.