Elsevier

Surgery

Volume 145, Issue 6, June 2009, Pages 651-658
Surgery

Original Communication
The nature of general surgery resident performance problems

https://doi.org/10.1016/j.surg.2009.01.019Get rights and content

Background

Residents with performance problems are challenging to program directors and complicate the work of other residents and health care providers. Having an effective, targeted remediation process to address these problems is dependent on being able to diagnose their nature. The purpose of this study was to identify residents who had serious, substantive, and recurring academic, clinical, and/or professional behavior problems, and to describe and classify their nature.

Methods

Raters performed a retrospective record review of general surgery categorical residents in one program over 30 years. Residents with substantial problems were reviewed, described, and classified independently by 3 raters.

Results

Seventeen residents had serious enough performance problems to be included. Four had only 1 class of problem (3 were professional behavior problems). Eight residents had 2 problems each (5 academic and clinical performance problems; 3 clinical performance and professional behavior problems). Five residents had 3 problems. The number of performance problem facets per case varied from 11 to 2 with an average of 5.9 facets. Relations with health care workers was identified most frequently, followed closely by insufficient knowledge. Poor communication was third. Performance problems of 14 residents (82%) were identified in their first year. For 15 cases, the resident had unresolved performance problems at the end of the program.

Conclusion

There are 2 possible explanations for our findings: (1) resident problems similar to these are refractory to remediation; (2) treatments used historically are not well designed for the problems. Choosing among the 2 explanations will require developing remediation strategies targeted to specific patterns of performance problems.

Section snippets

Methods

We performed a retrospective record review of all (n = 78) general surgery categorical residents in 1 general surgery program since its inception in 1977 until completion of the 2005–06 academic year. Five primary data sources were reviewed for each resident: global numeric ratings and narrative evaluations of residents for each rotation, memoranda of record for advisor meetings with residents, minutes and other records of end-of-year decision meetings about resident progress, memoranda and

Inter-rater agreement

Three raters were used to evaluate records. For the 10 inter-rater agreement cases, all 3 raters agreed on the problem status (serious problems, no serious problems) for 7 of the 10 cases. Two raters agreed on the problem status for the other 3 cases. For 2 of the 10 cases, all 3 raters agreed there was no problem. Two of the raters agreed there was no problem for 2 additional cases. Therefore, the majority of raters agreed that there was no problem for 40% of the cases in the inter-rater

Discussion

In summary, we identified 17 cases (22%) where residents had serious, substantive performance problems during their training program. This finding is similar to that of Bergen et al,4 who reported a prevalence of 21% in another general surgery residency program.

Virtually all problems in our study proved to be chronic; they were still present at the end of training in every case where this could be determined. Reamy and Harman2 reported that attitudinal problems are “more refractory to

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