Emotional Intelligence FM Residents and Reentry Physicians Behavioral
Emotional Intelligence, FM Residents and Reentry Physicians Behavioral Science Forum 2009 Anita R. Webb Ph. D, Joane G. Baumer MD and Richard A. Young MD JPS Health Network, Fort Worth, TX
Please complete the brief exercise on the first page.
Key Points • • EI assessment and teaching tools are widely used in business and academic settings worldwide (2007 presentation at www. fmdrl. com). The medical community has not expressed much interest in EI (2008 at www. fmdrl. com). JPS continues to investigate longitudinal EI skills in residency training. Physicians may also benefit from EI training after graduation from residency.
OVERVIEW • • ‘IQ alone explains surprisingly little of achievement at work or in life. ” 4% - 25% Study of Harvard grads in medicine, law, teaching and business: Scores on entrance exams had zero or negative correlations with eventual career success. • (Cited in Goleman, D. Working with EI. New York: Bantam, 1998, p. 19. )
Medical Education: Three Curriculum Needs 1. “Help physicians become proficient in recognizing and managing personal feelings, beliefs, values and needs • That can subconsciously affect their relations with self and others. ” (p. 2) • 2. Interviewing and communication skills • 3. Training as managers and team members • • Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum development for medical education. Baltimore: Johns Hopkins 1998.
Curriculum Needs (continued) • • Ability to recognize and adapt to affective states in one’s self and others is Thought to connote effective, compassionate doctor-patient communication. • Stratton TD, Saunders JA, Elam CL. Changes in medical students’ emotional intelligence: an exploratory study. Teaching and learning in medicine 2008; 20(3): 279 -84.
Residency: EI Research (handout) • Three empirical studies to date (2002 -2008) • • • Family Medicine, Anesthesia, Surgery Used self-report only to measure EI Were cross-sectional (vs. longitudinal) Did not address EI training Did not confirm predicted correlations between EI, patient satisfaction, resident performance or resident maturation.
JPS EI Research • • • Purpose: Evaluate use of EI tools in residency Hypothesis: Training can increase resident EI Design: Longitudinal with control group Tool: 360 degree EI survey • Ratings by self, faculty, nurses, residents Training: EI coaching
JPS Project (cont. ) • • Compare EI scores of two staggered classes of second-year residents • Intervention class receives EI coaching • Control group class: No coaching • 21 residents per class Approved by the JPS Health Network Internal Review Board
Phase I: Control Group • • • EI testing at the end of second year Purpose: establish R-2 baseline EI scores Preceded intervention group to avoid possible “trickle down” effect of training
II and III: Intervention Group • • • Phase II • EI pretest at the end of first year Intervention • EI coaching during second year Phase III • EI Post-test at end of second year
EI Coaching • • Adult Learning Model Trainee determines • Learning goals • Extent of contact with coach • Extent of effort expended to pursue learning goals • Endpoint/termination of coaching
EI Coaching: Steps • • • Individual meeting with resident to review test results: 1. Discuss resident’s career goals prior to presenting test results: Vision 2. Explain EI Competencies • Competency: “Personal trait or set of habits that leads to more effective or superior job performance” • (continued)
Coaching (continued) • • 3. Review resident’s EI scores • Focus on strengths • Compare Self/Other scores (360 survey) 4. Promote self reflection on Competencies • How do the scores support the resident’s career goals/vision? • (continued)
Coaching (continued) • • 5. Invite resident to select which EI Competencies to address via coaching • Not necessarily the weakest scores • Resident prioritizes 1 -3 initially 6. Provide a menu of learning activities to strengthen first targeted Competency • (continued)
Coaching (continued) • • • 7. Continue meeting on a regular basis • Review results of learning activities • Offer feedback (www. fmdrl. org) • Support, encourage, challenge 8. Return to Step 5 (target another Competency) as resident progresses 9. Post-test 10 months later to measure progress
Coaching: Example • • • The resident scores moderately on EI Competence of “Positive Outlook” Resident wants to develop stronger positive attitude for pursuing professional goals Suggested Learning Activities • Study the science of Positive Psychology • Psychology Website and Power. Point • Practice Positive Psychology exercises
Tool: Emotional and Social Competence Inventory (ESCI) • • • 360 degree survey (www. haygroup. com) Developed by academic psychologists 20+ years of research in academic (MBA students) and business communities Extensive worldwide database Well-validated, 72 items, 10 -20 minutes (Requires certification to administer)
JPS 360 Degree Raters • • • Self-rating plus six “Other” raters • At least two “Others” required by ESCI Two assigned raters • Faculty advisor and clinic nurse Resident chooses four more raters • Another faculty • One FM resident from each class
Phase II Results: Control group vs. Intervention group Pre-test scores • • Global EI research finding: EI scores tend to increase with age and training. Therefore: JPS Hypotheses • 1. R-2 (control group) scores will exceed R-1 (intervention group) pretest scores. • 2. Intervention group post-test scores one year later will exceed control group scores due to coaching.
Table I: Phase I and II Scores (See Handout) Self Other Self Ratings Cont Intrv Cont Other Intrv Norms S. D. Organizational Awareness 4. 22 4. 31 4. 50 4. 30 . 33 Teamwork 4. 16 4. 34 4. 32 4. 47 4. 29 . 37 Positive Outlook 4. 10 4. 12 4. 31 4. 45 4. 20 . 34 Adaptability 3. 98 3. 89 4. 21 4. 34 4. 18 . 33 Emotional Self Control 3. 97 3. 95 4. 20 4. 45 4. 22 . 40 Conflict Management 3. 93 3. 78 4. 12 4. 15 3. 92 . 34 Empathy 3. 92 3. 98 4. 20 4. 38 3. 96 . 37 Self-Awareness 3. 77 3. 74 4. 01 4. 18 3. 79 . 33 Achievement Orientation 3. 75 4. 11 3. 81 4. 47 4. 34 . 32 Coach and Mentor 3. 71 3. 59 4. 07 3. 83 4. 03 . 43 Inspirational Leadership 3. 66 3. 73 4. 02 4. 18 3. 99 . 43 Influence 3. 61 3. 66 3. 95 4. 09 4. 00 . 34 3. 90 3. 93 4. 12 4. 29 4. 10 MEAN Frequency of behavior: 1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = consistently Norms are for Other ratings only: N. American sample (N =1577), all ages and job levels
Results: Pretest Self Ratings • • • N = 19/21 (91% return rate both classes) Mean scores: 3. 90 (R-2) vs. 3. 93 (R-1) on 5 point scale • Did not support Hypothesis #1 • R-2 scores did not exceed R-1 scores Each class outscored the other on half of the Competencies • With different perceived strengths
Results (cont. ): Other Ratings • • • 68% /67% return rates (Control/Interv. ) The R-1 intervention group had higher Other ratings than the R-2 control group. • 4. 29 mean vs. 4. 12 mean • Exception: “Coach and Mentor” Ratings by Others were higher than Self ratings on every Competency for both control and intervention classes.
High vs. Low Other Ratings • • • Pretest group means: 4. 29 Other/3. 93 Self Subsample of high Other vs. low Self scoring residents • 4. 68/3. 80, 4. 61/3. 85, 4. 45/3. 64, 4. 51/3. 44 False modesty? Higher standards? Lack of Self-Awareness and/or Social Awareness (not aware of their impact)? (One of these residents came for coaching. )
Self-Assessment Issues • • “Humans may be pre-disposed to be poor self-assessors. ” “Physicians are poor self-assessors (like other professionals). ” • Barnes B. The role of continuing professional development in assessing and addressing physician competence. Coalition for Physician Enhancement meeting, Chicago, Sept. . 2009.
Lower Other Ratings • • • Subsample of lower Other scoring residents 3. 68/4. 46 Self, 4. 13/4. 24 Self [M=4. 29/3. 93] • Hypotheses? (Next slide) • (One came for coaching. ) No Self Rating (only 2): 4. 04, 3. 94 • Hypotheses? • (One came for coaching. )
Low Other/High Self scores • “Poor performers over-estimate competence. ” • Barnes, B. The role of continuing professional development in assessing and addressing physician competence. Coalition for Physician Enhancement meeting, Chicago, September 2009.
ESCI NORMS • • • Based on North American sample • N =1577, all ages From Business/Industry • Across all job levels and functions • From entry-level worker to CEO The norms refer to “Other” ratings only.
NORMS (continued) • • • Composite mean scores: 4. 10 Norms • 4. 12 Control group • 4. 29 Intervention group R-2 Control group ratings were above the norm on 9 of 12 Competencies. R-1 Intervention group pretest ratings were above the norm on 11 of 12 Competencies.
Phase II: Conclusions • • • Both classes were favorably perceived by others in the workplace in terms of EI. Basically equivalent total Self scores Higher Other vs. Self scores: Residents are modest about their own EI skills. Higher Other scores for R-1 vs. R-2 The Intervention group may have been a stronger class at the time of entry.
“Strong Class”? • • This intern class had impressive academic records including high USMLE scores. Also set a record for high In-Training scores Halo effect? (But academic scores were confidential. ) Question: For medical students, does cognitive intelligence correlate with EI?
Phase II: Limitations • • No entry scores to compare each class No surveys from patients No norms for the medical community Weak measure of external validity • • See 2007 presentation at www. fmdrl. org “Emotional Intelligence and the ACGME Competencies”
Phase III Intervention Group Post-test Scores After EI Coaching
Resident Response to Coaching • • Adult learning model: voluntary • Only nine residents came to review their EI pre-test scores • Only six returned for a second session • Only one came for a third session No resident received full EI coaching.
Interpretation of Post-test Results • • Lack of resident interest? • No perceived need or value? • Lack of protected time? Since the intervention did not occur, • The post-test scores actually reflect • “Natural” longitudinal development • Rather than the effect of EI coaching.
TABLE 2 Intervention Group: Pretest vs. Post-test Scores (See Handout) Self Pre RATINGS Self Post Other Pre Other Post Norms S. D. Organizational Awareness 4. 22 4. 20 4. 53 4. 30 . 33 Teamwork 4. 34 3. 89 4. 47 4. 09 4. 29 . 37 Positive Outlook 4. 12 4. 20 4. 45 4. 48 4. 20 . 34 Adaptability 3. 89 3. 92 4. 34 4. 40 4. 18 . 33 Emotional Self -Control 3. 95 3. 86 4. 45 4. 51 4. 22 . 40 Conflict Management 3. 78 3. 96 4. 15 4. 38 3. 92 . 34 Empathy 3. 98 4. 05 4. 38 4. 49 3. 96 . 37 Self-Awareness 3. 74 3. 82 4. 18 4. 29 3. 79 . 33 Achievement Orientation 4. 11 4. 17 4. 47 4. 56 4. 34 . 32 Coach and Mentor 3. 59 3. 83 4. 39 4. 03 . 43 Inspirational Leadership 3. 73 3. 85 4. 18 4. 34 3. 99 . 43 Influence 3. 66 3. 78 4. 09 4. 26 4. 00 . 34 3. 93 3. 97 4. 29 4. 39 4. 10 MEAN Frequency of behavior: 1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = consistently Norms are for Other ratings only: N. American sample (N =1577), all ages and job levels
Post-test SELF-Ratings • • • N = 20/21 (95% return rate) Mean = 3. 97 (5 -point scale) Range: 3. 78 - 4. 20 Highest (and also high on pretest) • Organizational Awareness • Positive Outlook Lowest: Influence (as on pretest)
Post-test Self Ratings (cont. ) • • • Scores increased for nine competencies • Especially: Coach/Mentor (3. 89 vs. 3. 59) • And Conflict Management (3. 96 vs. 3. 78) Three decreased: Teamwork (3. 89 vs. 4. 34) • Emotional Self-Control and Organizational Awareness (barely) Mean post-test Self score was slightly higher than pretest: 3. 97 post vs. 3. 93 pre
Post-test OTHER-Ratings • • • 66% return rate Mean: 4. 39 Range: 4. 09 - 4. 56 Ratings by Others were significantly higher than Self ratings for every Competence (Note: Recall that intervention group R-1 pretest ratings by Others were higher than R -2 control group ratings by Others. )
Post-test OTHER-Ratings (cont. ) • • • Highest: Achievement Orientation (also high on pretest) Lowest: Influence (as on pretest) All increased, especially Coach/Mentor (as also on Self post-test scores) • Exception: Teamwork (as on Self ratings) • In contrast to Self ratings, even Self. Control increased on Other ratings
Statistically Significant Pre/Post Changes • • SELF • Increased: None statistically significant • Decreased: Teamwork (P<. 001) OTHER • Increased: Coach and Mentor (P<. 001) • Decreased: Teamwork (P<. 001)
Meaning of Two Declining Scores? • • Self and Other: Teamwork • 3. 89 post-test vs 4. 34 pretest by Self • 4. 09 post-test vs 4. 47 pretest by Other • “Now the Leader, not a team player”? Self: Why not increased ratings for • Emotional Self-Control • Organizational Awareness
ESCI Norms: OTHER Ratings • • Norms are for Other ratings only Pre- and Post-test composite mean ratings were higher than norms: 4. 29/4. 39 vs. 4. 10 Pretest : higher than the norms on all but Coach/Mentor and Leadership Post-test: higher than the norms on all but Teamwork
The Bigger Picture: Four EI Domains SELF Awareness (Insight) SOCIAL Awareness (Empathy) SELF Relationship Management (Self Control) (Social Skills)
ESCI Domain Scores (handout) • Self and Other Scores for Control, Pre- and Post-test Groups: • I. Self-Awareness: Range = 3. 74 - 4. 29 • II. Self-Management: 3. 95 - 4. 49 • III. Social Awareness: 4. 07 - 4. 51 • IV. Relationship Management: 3. 81 - 4. 35
Domain Scores • • Social Awareness had the highest ratings by both Self and Others in all three Phases • 1. Empathy: Sensing others’ feelings and perspectives, and taking an active interest in their concerns • 2. Organizational Awareness: Reading a group’s emotional currents and power relationships Self-Management almost as high
Domain Scores (continued) • • • Lowest scores across all three groups were for Self-Awareness: 3. 74 - 4. 29 • Consists of a single Competence • Emotional Self-Awareness: Recognizing one’s emotions and their effects WHY lowest? Implications?
Medical Education and Training • • “Unfortunately, medical training has been shown to erode some of the very attributes it purports to instill in students. ” Including EI • Stratton TD, Saunders JA, Elam CL. Changes in medical students’ emotional intelligence: an exploratory study. Teaching and Learning in Medicine, 2008; 20(3), 279 -284.
Erosion (continued) • • Also confirmed in body of literature for empathy research In medical school and residency training • (Special section on “Empathy” in September 2009 issue of Academic Medicine)
“Coached” Subgroup • • • Subgroup of Intervention group residents who had at least one coaching session Scores did not differ from other residents • On either Self or Other ratings • For pretest or post-test Conclusion: Residents who kept their initial appointments for coaching did not differ from non-attenders on EI scores.
Phase III: Limitations • • Possible “Ceiling Effect” • High pretest scores for intervention group left little room for increase on post-test? Faulty Coaching Plan • Lack of protected time • Failure to engage residents
Conclusion: Coaching • • • EI coaching was not successful at this time in our program. Coaching was not pursued by residents, per adult learning model. Targeted coaching with select residents may have been more successful.
Phase III: Conclusions • • • EI scores for the intervention group were higher than the control group on both pre- and post-tests: Stronger class. Post-test scores for the intervention group were higher than their pretest scores even in the absence of EI coaching. Supports EI theory: EI “naturally” increases with age, experience and education/training.
Phase IV? • • • 1. Option for a second post-test next year. • Would result in longitudinal residency profile • End of R-1 year to graduation • Depends on resident and faculty commitment 2. Focused intervention for specific residents? • Determine faculty and resident interest • Offer choice to work with advisor or EI coach What do you suggest?
Resident EI: Future Research Agenda • • • Patient ratings of resident EI Correlation between resident EI scores and: • Patient satisfaction • Patient health outcomes • Resident satisfaction • Resident clinical performance After residency: clinical performance, career satisfaction, and “life success”
After Residency • • Few physicians currently in practice have had formal EI training. Why add EI training to the residency curriculum at this time? • ACGME competencies: Measure, teach • Prevent physician problems after graduation
Part Two: Problems After Residency Handling a stressful career choice: • Conflicting roles and responsibilities • Difficult encounters with patients, staff, colleagues, administrators, etc. • Malpractice fears/threats • Patient and/or hospital complaints • Difficult healthcare environment in U. S.
“Problem Doctors” • “Physician performance failures are not rare and pose substantial threats to patient welfare and safety. ” • • Leape LL, Fromson JA. Problem doctors: Is there a system-level solution? Ann Intern Med 2006; 144: 107 -115. How many of these failures could be prevented by stronger physician EI skills?
Medical School Problems • “Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school. ” • Papadakis MA, Teherani A, Banach MA et al. Disciplinary Action by Medical Boards and Prior Behavior in Medical School. New Prior Behavior in Medical School. N England Journal of Med 2005; 353: 2673 -2682.
Residency Remediation? • • Apparently, residency training did not • resolve the problem of unprofessional behavior for medical students who were • later disciplined by medical boards. EI theory provides a model and tools to • identify, measure, remediate, and track professionalism for students, residents, • and physicians in practice.
Practice Interruptions • • • Extended personal illness Family responsibilities: e. g. childrearing, caretaking for ill parents Accept a non-clinical medical position (e. g. administrative) “Burn-out” Loss of hospital privileges Legal sanctions on medical license
Extended Interruption • • • When physicians stop practicing medicine for an extended period of time (e. g. two years in Texas), Their medical license may not be eligible for renewal Due to concerns about erosion of competence.
Physician Shortage • • Expected to worsen due to multiple factors. Difficult to “catch up” due to extended length of education. Experienced physicians have insight that cannot be taught. Returning these “interrupted” physicians to practice would benefit the community.
Re-Training • • • Short of completing another residency, • What mechanism could allow these physicians to return to medical practice? An international movement to re-train physicians has spawned a number of “re -entry” programs in North America. Umbrella organization: Coalition for Physician Enhancement (CPE)
Where to turn for help? • • • “The Coalition for Physician Enhancement (CPE) is a consortium of professionals “With expertise in quality assurance, medical education, and the assessment, licensing, and accreditation of referred physicians “Seeking higher levels of performance in patient care. ” • www. physicianenhancement. org
CPE: Mission Statement • • “To support and develop expertise in assessment and enhancement when competence and/or performance are to be assessed. ” Six organizations that offer re-training for physicians at sites in: • Canada, Denver, New York • San Diego, Texas, Wisconsin
Example: Texas • • • Newest re-entry program: 2008 Application and assessment through “K -Star” at Texas A&M University • Week long extensive assessment Re-training at JPS in Fort Worth • Twelve-week structured program • Based on the six ACGME Competencies
K-STAR: Assessing Competencies • • Capacity: Physical, cognitive, “personality” Motivation: Why return to practice? Distractors: e. g. marital, substance abuse Alienation from medical community The Disruptive Physician Organizational skills EI Competencies
JPS Re-Entry Program • • • Referral: Medical boards, hospital, self Launched 2008 • Eight physicians graduated to date • Five accepted for next session Preferable to enroll in small groups (3 -5) • Enhances professionalism discussions • Functions as de facto support group
JPS “Mini-Residency” Curriculum • • • Weekly activities • Clinical: Five half-days (with preceptor) • Redacted chart review group sessions • Behavioral Science group: including EI, ethics • Daily Noon Conference at residency program • Didactic modules online Procedure Log Individual QI Project
Reasons for Leaving Practice • • • Life stress: “I ran away. ” • #1: Left medical career, spouse, country • #2: Left career, traveled the country with family, lived in trailer, jobless Early voluntary retirement (not due to illness, etc. ): “It wasn’t fun any more. ” New career in higher education administration Hospital concerns about skills due to complaints Substance abuse License revoked due to colleague complaints
Role of Emotional Intelligence • • Self Awareness: burn-out, lagging skills Self Management: substance abuse, fleeing Relationship Awareness: colleagues Relationship Management: colleague complaints, administrators, family problems
JPS Reentry: EI Assessment • • • Unable to use ESCI for re-entry physicians due to requirements for “Other” raters • Must have regular, frequent contact • Within the last 12 months Difficult to arrange pretest with colleagues Unable to use same raters for bothpretest and post-test for direct comparison.
Evaluation of Participants • • • 360 degree evaluations at end of program • Preceptor, Nurses, and Patients • Brief 10 -item Likert scale surveys Limitation: No “pre-test” scores for comparison Approved by JPS Internal Review Board
Summary: EI and Physician Training • • EI training in residency may benefit • Residents: for relationships, teamwork, leadership, stress management • Faculty: to teach ACGME competencies • Compassion, communication and interpersonal skills, professionalism EI training may benefit physicians in practice and seeking to return to practice.
Future of EI in Medicine • • • Medical administration and nursing are interested. • Have published research supportive EI • See 2008 presentation at www. fmdrl. com Physicians: Have not expressed as much interest Research needed to evaluate potential value of EI for physicians • Residency training • Continuing education • Physicians seeking Re-Entry
Conclusions • • • Contrary to plan, EI Coaching was not used in the residency study. EI skills increased in our residents over time even without specific EI training. Research is needed to determine whether EI coaching has a role in residency training or for reentry physicians.
THE END Thank You! awebb@jpshealth. org jbaumer@jpshealth. org
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