A tool for self-assessment of communication skills and professionalism in residents
- Andrew B Symons†1Email author,
- Andrew Swanson†1,
- Denise McGuigan†1,
- Susan Orrange†2 and
- Elie A Akl†3
© Symons et al; licensee BioMed Central Ltd. 2009
Received: 08 August 2008
Accepted: 08 January 2009
Published: 08 January 2009
Effective communication skills and professionalism are critical for physicians in order to provide optimum care and achieve better health outcomes. The aims of this study were to evaluate residents' self-assessment of their communication skills and professionalism in dealing with patients, and to evaluate the psychometric properties of a self-assessment questionnaire.
A modified version of the American Board of Internal Medicine's (ABIM) Patient Assessment survey was completed by 130 residents in 23 surgical and non-surgical training programs affiliated with a single medical school. Descriptive, regression and factor analyses were performed. Internal consistency, inter-item gamma scores, and discriminative validity of the questionnaire were determined.
Factor analysis suggested two groups of items: one group relating to developing interpersonal relationships with patients and one group relating to conveying medical information to patients. Cronbach's alpha (0.86) indicated internal consistency. Males rated themselves higher than females in items related to explaining things to patients. When compared to graduates of U.S. medical schools, graduates of medical schools outside the U.S. rated themselves higher in items related to listening to the patient, yet lower in using understandable language. Surgical residents rated themselves higher than non-surgical residents in explaining options to patients.
This appears to be an internally consistent and reliable tool for residents' self-assessment of communication skills and professionalism. Some demographic differences in self-perceived communication skills were noted.
Excellent communication skills are essential to the practice of medicine. Effective communication during medical encounters has been associated with significant benefits in areas such as patient recall and understanding, adherence to treatment plans, symptom resolution, physiological outcomes, and medical decision-making, as well as satisfaction of both patients and physicians.[2, 3]
Positive doctor-patient relations can increase the patient's perceptions of physician competence. Research has shown that physicians who exhibit negative communication behaviors are more likely to have been sued in the past for malpractice than those with more positive doctor-patient relations. [5–8] Beckman, et al. found that in 70% of malpractice depositions, communication problems between physicians and patients were identified.
Several national organizations have recognized the importance of fostering and evaluating communication skills and professionalism in physicians in training and in practice.[1, 10–12] The Association of American Medical Colleges (AAMC) Medical School Objectives Project urges medical schools to teach these skills. The Accreditation Council for Graduate Medical Education (ACGME) has defined these skills as core competencies that programs have to train in and evaluate. Finally, the American Board of Internal Medicine (ABIM) includes an evaluation of communication skills and professionalism in the recertification process of practicing physicians.
The wide agreement on the importance of communication skills and professionalism challenges medical educators to develop effective methods and tools to evaluate them. Current evaluation methods in residency training programs include attending physician assessment, peer evaluation, standardized patient assessment, actual patient assessment, and self-assessment. [16–18] One of the available evaluation tools is the ABIM Patient Assessment survey, a widely used instrument for patient evaluation of physicians. [19–23]
The aims of this study were to evaluate residents' self-assessment of their communication skills and professionalism in dealing with patients, and to evaluate the psychometric properties of the ABIM Patient Assessment survey, modified as a self-assessment questionnaire for this purpose. Self-assessment, though it has some limitations, [24–30] may be used as part of a multi-source evaluation scheme for those studying and practicing medicine.[1, 10, 31–35]
Setting and participants
The Office of Graduate Medical Education of the University at Buffalo School of Medicine and Biomedical Sciences organizes a yearly core curriculum "master session" on professionalism. Residents in all of the 23 affiliated training programs are required to attend this master session at least once by the time they graduate from their residency.
We invited all residents attending the 2007 master session on professionalism to voluntarily participate in the study by completing a two-page anonymous questionnaire. We distributed the questionnaire at the beginning of the session along with other lecture-related material. At the end of the session, those who chose to participate left the survey in a box anonymously. The Institutional Review Board of the University at Buffalo approved the study.
The survey questionnaire was a modified version of the ABIM's Patient Assessment survey, which is part of the Patient and Physician Peer Assessment Module for maintenance of certification. The Patient Assessment survey includes 11 questions about different aspects of communication skills and professionalism of the physician. Patients rate each of these aspects on five-point Likert scales ranging from 1 (poor) to 5 (excellent). Lipner applied generalizability theory to the survey as administered to patients about their physicians. The variance component for participants was 0.01. The generalizability coefficient was 0.67 with a 95% confident interval of ± 0.14.
We modified the Patient Assessment survey to a physician self-assessment survey by using the third-person (e.g., "greeting them warmly") instead of the second-person (e.g., "greeting you warmly") while otherwise preserving the exact same wording. The questionnaire included additional questions related to resident demographic characteristics (age, sex), and educational characteristics (year of residency, country of graduation [U.S. versus international], number of years since medical school graduation, and specialty).
We performed a descriptive analysis (frequencies and percentages) of the demographic and educational characteristics of the participants. We conducted factor analysis to search for items showing a high level of commonality. Prior to conducting the factor analysis, we tested the suitability of the scale using the Kaiser-Meyer-Oklin (KMO) test and the Bartlett's Test of Sphericity. Because the data were skewed toward the higher values, we re-categorized the answer choices into three groups: "poor or fair," "good," and "very good or excellent."
We then conducted a series of analyses to evaluate the psychometric properties of the survey questionnaire. We measured internal consistency reliability (Cronbach's alpha) to assess whether all the items were contributing to the measurement of professionalism. We also measured inter-item gamma scores to examine the level of relationship between the items in the questionnaire. Gamma replaced the standard Pearson r correlation due to the categorical nature of the results. We assessed association utilizing cross tabulation techniques with chi square statistics to determine the discriminative validity of the proposed instrument, regardless of the demographic and educational characteristics of the participants. In addition, we calculated the Kruskal-Wallis K Independent Samples test to examine differences in total score across demographic and educational groups. The total score was computed by tabulating the sum of all 11 items to provide a continuous measure of communications skills and professionalism. We used SPSS version 13.0 (SPSS, Inc., Chicago, Illinois) for all analyses.
Frequency (N = 130)
Post Graduation Year
Post-Greater than Year 4
Graduate of U.S. medical schools
Graduate of medical schools outside the U.S.
Type of Residency *
Surgical or surgical subspecialty
The scale was suitable for the factor analysis: the KMO test value was 0.806 (recommended minimum level is 0.6), and the Bartlett test value was statistically significant (p < 0.001).
Rotated Component Matrix
Interpersonal Relations 1
Conveying Medical Information 2
Item 2: Greeting them warmly; calling them by the name they prefer; being friendly, never crabby or rude
Item 3: Treating them like they're on the same level; never "talking down" to them or treating them like a child
Item 5: Showing interest in them as a person; not acting bored or ignoring what they have to say
Item 1: Telling them everything; being truthful, upfront and frank; not keeping things from them that they should know
Item 4: Letting them tell their story; listening carefully; asking thoughtful questions; not interrupting them while they're talking
Item 10: Using words they can understand when explaining their problems and treatment; explaining any technical medical terms in plain language
Item 11: How would you rate your level of professionalism?
Item 9: Explaining what they need to know about their problems, how and why they occurred, and what to expect next
Item 7: Discussing options with them; asking their opinion; offering choices and letting them help decide what to do; asking what they think before telling them what to do
Item 6: Warning them during the physical exam about what you are going to do and why; telling them what you find
Item 8: Encouraging them to ask questions; answering them clearly; never avoiding their questions or lecturing them
Items loading strongly on component two (conveying medical information) include; Item 6 (warning the patient prior to a physical exam), Item 7 (discussing options with the patient, offering choices, etc.), Item 8 (encouraging the patient to ask questions), and Item 9 (explaining to the patient what they need to know about their medical issue). There was overlap on two items, Item 10 (using words the patient can understand) and Item 11 (overall level of professionalism). Of particular note is the overlap between the two components on Item 11 (overall level). Additional data should be collected to further examine this overlap.
Item 10 loads in both component 1 (interpersonal relations) and component 2 (conveying medical information) indicating that clarity in speaking is important in interpersonal relations and conveying medical information. However, it loads stronger in component 1 (0.563 versus 0.369).
Psychometric properties of the survey questionnaire
The Cronbach's alpha level was 0.86, well above the minimally acceptable level of 0.7. In addition, each component's internal consistency reliability was assessed. Component 1 (Interpersonal Relations) showed an internal consistency reliability of 0.82 and component two (Communication and Professionalism) showed an internal consistency reliability of 0.80. Based on these results, both components show a high level of internal consistency reliability, suggesting that each component's items are measuring the main idea of the components.
The Kruskal-Wallis K Independent Samples test resulted in no significant differences between groups in each of the demographic and educational variables. The lack of significant differences shows that the total score of professionalism is not influenced in a significant way by membership in any one of these groups.
The gamma tests showed significant associations between some of the self-rating items and some of the educational and demographic characteristics. Males, compared with females, rated themselves significantly more positively on Item 1 (telling your patient everything, etc.; p = 0.032), Item 9 (explaining to your patient what they need to know, etc.; p = 0.040), and Item 10 (using words they can understand, etc; p = 0.017).
There were two statistically significant differences between graduates of U.S. medical schools and graduates of medical schools outside the U.S. International graduates, compared with U.S. graduates, rated themselves significantly more positively on Item 4 (letting patients tell their story, etc; p = 0.003). On the other hand, U.S. graduates, compared with international graduates, rated themselves significantly more positively on Item 10 (using words they can understand, etc.; p = 0.003).
Finally, residents in surgical specialties, compared with non-surgical specialties, rated themselves significantly more positively on Item 7 (discussing options with patients, etc.; p = 0.005).
The main utility of our educational exercise (the professionalism presentation) was to raise resident awareness regarding issues of doctor-patient communication and to expose them to a tool which has been used to survey patients about their perceptions of their doctors. Our psychometric analysis of the adaptation of the ABIM patient satisfaction survey for resident self-assessment shows highly acceptable levels of internal consistency reliability. In addition, factor analysis shows us the beginning development of two distinct components of professionalism ("interpersonal relations" and "conveying medical information"). These two components allow for the potential creation of separate sub-scales of professionalism. Of particular interest is the overlap on the two components of overall level of professionalism. This overlap could potentially be due to a number of influences. For instance, it could be that both subscales adequately measure overall professionalism and the item is important in both components. One might speculate that items related to "conveying information" are fairly mechanistic, whereas items related to "interpersonal relations" require being more in tune with the patient's emotions. Ginsburg and colleagues noted that the nature of professionalism is context-specific. Perhaps physicians need to rely on a different set of communication skills depending on the context of the clinical interaction (e.g., delivering a poor prognosis for a cancer versus describing the risks/benefits/alternatives of epidural anesthesia during labor). The issue of "sub-scales" of professionalism could be explored further by administering the survey to patients and residents immediately after a clinical encounter and noting the context of the interaction.
The results also show significant associations between self ratings and certain participant characteristics. Males tended to rate themselves higher than females on certain items. While this might be their self-perception, reality may prove contrary. In a study by Minter, female surgical residents were found to underestimate their skills compared to attending physician evaluation. Additional studies have found that females score better than males after a training course in communication skills, [39–42] female physicians engage in more patient-centered communication than do males, and female graduates of medical schools outside the U.S. received slightly higher communication and interpersonal skills ratings than did male graduates of medical schools outside the U.S. on the United States Medical Licensing Examination™ Step 2 Clinical Skills exam. When the original ABIM survey was administered to patients for purposes of assessing physicians, female doctors received higher overall professionalism ratings from their patients.
Foreign graduates reported doing a better job at listening to their patients, whereas U.S. graduates reported using more understandable language. This may have more to do with confidence in English language proficiency rather than basic communication skills; foreign graduates might listen more closely so as not to misunderstand their patients, and their lack of confidence in speaking English might cause them to perceive that they are not speaking in language which is easily understandable to their patients. This would need to be pursued in a further study, particularly comparing resident self-assessment to actual patient perception.
Surgical residents rated themselves more positively in discussing options with patients compared to residents in non-surgical specialties. The quality of these communication skills has a substantial impact on patient outcomes, including superior recovery rates in patients undergoing surgical procedures, reduced need for analgesic use to treat post-operative pain, and improved emotional and functional adjustment in adult cancer patients. We might speculate that surgery residents' perceptions of their ability to discuss options might be higher than non-surgical residents' because, often in surgery, the options are more concrete (i.e., surgery versus no surgery) whereas patient management options in the non-surgical specialties are often less concrete (i.e., one medication regime versus another medication regime) and perhaps more difficult to articulate to patients.
Current schemes for evaluating communication skills and professionalism in students and residents have flaws when used in isolation. For instance, although standardized patients have been shown to be useful in evaluating the mechanics of clinical and communication skills, their reliability in assessing elements of professionalism is less established. These settings may also be considered contrived. Faculty evaluations of professional behavior using instruments with Likert scales have been shown to have poor reliability, primarily because the attending physician usually does not interact extensively with the student in the work environment. [49–51] Peer evaluations, though they provide good information about interpersonal skills, are problematic because of the "halo effect" (i.e., if a person is popular, this "halo" may affect the evaluation of specific traits) and because peers are often reluctant to comment on poor behavior in colleagues.[1, 10, 16, 52, 53] Actual patient evaluations would seem to be the best source of evaluation of communication skills, but can be influenced greatly by the setting in which they are performed.
Recent reviews of self-assessment in the health professions raise questions about the ability of professionals to generate accurate judgments of their own performance.[24, 25] Of even more concern is that those who perform the least well on external assessment may also overrate their performance on self-assessment exercises.[24, 26–28] Most studies of self-assessment are in areas of technical knowledge and ability. Even in concrete areas such as these, self-assessment has been found to be inaccurate.[29, 30, 37] This may be of even more concern when the area of assessment is laden with value judgments, as is the case in communication skills and professionalism. In one study, medical residents perceived a high level of competence to discuss end-of-life issues, but failed to engage in recommended behaviors for such discussions. When surveys use self-assessment, they are subject to social desirability bias. This may limit the usefulness of these self-assessments to formative assessment and the formation of personal goals.
It is thought that a more representative picture of professional behavior can be obtained by surveying a variety of patients and people in the healthcare team because they interact with students and residents on a more regular basis and may provide a more informative picture of professional behavior throughout their academic career.[1, 10, 31–33] This type of assessment is referred to as a "360-degree Evaluation." Resident self-assessment of professionalism skills may therefore be more useful when compared with the assessments made by others.[34, 35]
There may also be educational benefit simply by the process of self-reflection. Reflection, both on the process and content of learning can help students to monitor their own learning.[56, 57] Reflection-in-learning is related to readiness for self-regulation of learning and may be conducive to enhanced diagnostic ability. Studies have found that a greater effort of reflection is associated with a more positive or meaningful learning experience.[58, 59] The rationale for encouraging reflection in the promotion of self-directed learning is extensive. Actually, reflection is conceived as one of the metacognitive skills or cognitive regulation strategies required for the development of self-regulated learning, from a theoretical viewpoint.
Through psychometric analysis, we have shown that the adaptation of the ABIM patient satisfaction survey is reliable for self-assessment of communication skills in residents. Although the face validity of the items has been reviewed elsewhere, we hope to further establish the validity of this tool for resident self-assessment by administering the survey to patients and residents immediately following a clinical encounter, and comparing aggregate patient evaluations with the residents' own self-assessment of communication and professionalism skills. Although, as part of the ABIM Maintenance of Certification process, physicians are asked to answer the patient survey questions as a "self-assessment," we are aware of no published studies comparing the physician and patient data. We would like to explore comparing these data with results we have obtained or will obtain in our own studies of resident physicians. We would also like to use the resident self-assessment in conjunction with other resident evaluation methods currently in place at our institution.
The authors would like to acknowledge Andrew Danzo for reviewing and editing the paper.
- Stern DT: Measuring medical professionalism. 2006, Oxford; New York: Oxford University PressGoogle Scholar
- Stewart MA: Effective physician-patient communication and health outcomes: a review. CMAJ. 1995, 152: 1423-1433.Google Scholar
- Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M: Evidence on patient-doctor communication. Cancer Prev Control. 1999, 3: 25-30.View ArticleGoogle Scholar
- Moore PJ, Adler NE, Robertson PA: Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med. 2000, 173: 244-250. 10.1136/ewjm.173.4.244.View ArticleGoogle Scholar
- Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA: Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA. 1994, 272: 1583-1587. 10.1001/jama.272.20.1583.View ArticleGoogle Scholar
- Hickson GB, Clayton EW, Githens PB, Sloan FA: Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA. 1992, 267: 1359-1363. 10.1001/jama.267.10.1359.View ArticleGoogle Scholar
- Levinson W, Roter D: Physicians' psychosocial beliefs correlate with their patient communication skills. J Gen Intern Med. 1995, 10: 375-379. 10.1007/BF02599834.View ArticleGoogle Scholar
- Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM: Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997, 277: 553-559. 10.1001/jama.277.7.553.View ArticleGoogle Scholar
- Beckman HB, Markakis KM, Suchman AL, Frankel RM: The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994, 154: 1365-1370. 10.1001/archinte.154.12.1365.View ArticleGoogle Scholar
- Arnold L: Assessing professional behavior: yesterday, today, and tomorrow. Acad Med. 2002, 77: 502-515.View ArticleGoogle Scholar
- Stern DT, Friedman Ben-David M, Norcini J, Wojtczak A, Schwarz MR: Setting school-level outcome standards. Med Educ. 2006, 40: 166-172. 10.1111/j.1365-2929.2005.02374.x.View ArticleGoogle Scholar
- Stern DT, Frohna AZ, Gruppen LD: The prediction of professional behaviour. Med Educ. 2005, 39: 75-82. 10.1111/j.1365-2929.2004.02035.x.View ArticleGoogle Scholar
- Learning objectives for medical student education – guidelines for medical schools: report I of the Medical School Objectives Project. Acad Med. 1999, 74: 13-18.Google Scholar
- Toolbox for the evaluation of competence. [http://www.acgme.org]
- Improve your Practice With PIMs. [http://www.abim.org/online/pim/demo.aspx]
- Lynch DC, Surdyk PM, Eiser AR: Assessing professionalism: a review of the literature. Med Teach. 2004, 26: 366-373. 10.1080/01421590410001696434.View ArticleGoogle Scholar
- Terry R, Hiester E, James GD: The use of standardized patients to evaluate family medicine resident decision making. Fam Med. 2007, 39: 261-265.Google Scholar
- Franzese CB: Pilot study of an Objective Structured Clinical Examination ("the Six Pack") for evaluating clinical competencies. Otolaryngology Head Neck Surg. 2008, 138: 143-148. 10.1016/j.otohns.2007.10.017.View ArticleGoogle Scholar
- Lipner RS, Blank LL, Leas BF, Fortna GS: The value of patient and peer ratings in recertification. Acad Med. 2002, 77: S64-66. 10.1097/00001888-200210001-00021.View ArticleGoogle Scholar
- Fan VS, Reiber GE, Diehr P, Burman M, McDonell MB, Fihn SD: Functional status and patient satisfaction: a comparison of ischemic heart disease, obstructive lung disease, and diabetes mellitus. J Gen Intern Med. 2005, 20: 452-459. 10.1111/j.1525-1497.2005.40057.x.View ArticleGoogle Scholar
- Harris LE, Swindle RW, Mungai SM, Weinberger M, Tierney WM: Measuring patient satisfaction for quality improvement. Med Care. 1999, 37: 1207-1213. 10.1097/00005650-199912000-00004.View ArticleGoogle Scholar
- Rider EA, Hinrichs MM, Lown BA: A model for communication skills assessment across the undergraduate curriculum. Med Teach. 2006, 28: e127-134. 10.1080/01421590600726540.View ArticleGoogle Scholar
- Yudkowsky R, Alseidi A, Cintron J: Beyond fulfilling the core competencies: an objective structured clinical examination to assess communication and interpersonal skills in a surgical residency. Curr Surg. 2004, 61: 499-503. 10.1016/j.cursur.2004.05.009.View ArticleGoogle Scholar
- Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L: Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006, 296: 1094-1102. 10.1001/jama.296.9.1094.View ArticleGoogle Scholar
- Eva KW, Regehr G: Self-assessment in the health professions: a reformulation and research agenda. Acad Med. 2005, 80: S46-54. 10.1097/00001888-200510001-00015.View ArticleGoogle Scholar
- Hodges B, Regehr G, Martin D: Difficulties in recognizing one's own incompetence: novice physicians who are unskilled and unaware of it. Acad Med. 2001, 76: S87-89. 10.1097/00001888-200110001-00029.View ArticleGoogle Scholar
- Lynn DJ, Holzer C, O'Neill P: Relationships between self-assessment skills, test performance, and demographic variables in psychiatry residents. Adv Health Sci Educ Theory Pract. 2006, 11: 51-60. 10.1007/s10459-005-5473-4.View ArticleGoogle Scholar
- Kruger J, Dunning D: Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999, 77: 1121-1134. 10.1037/0022-35184.108.40.2061.View ArticleGoogle Scholar
- Gordon MJ: Self-assessment programs and their implications for health professions training. Acad Med. 1992, 67: 672-679. 10.1097/00001888-199210000-00012.View ArticleGoogle Scholar
- Regehr G, Hodges B, Tiberius R, Lofchy J: Measuring self-assessment skills: an innovative relative ranking model. Acad Med. 1996, 71: S52-54.View ArticleGoogle Scholar
- Harris GD: Professionalism: part II – teaching and assessing the learner's professionalism. Fam Med. 2004, 36: 390-392.Google Scholar
- De Haes JC, Oort FJ, Hulsman RL: Summative assessment of medical students' communication skills and professional attitudes through observation in clinical practice. Med Teach. 2005, 27: 583-589. 10.1080/01421590500061378.View ArticleGoogle Scholar
- de Haes JC, Oort F, Oosterveld P, ten Cate O: Assessment of medical students' communicative behaviour and attitudes: estimating the reliability of the use of the Amsterdam attitudes and communication scale through generalisability coefficients. Patient Educ Couns. 2001, 45: 35-42. 10.1016/S0738-3991(01)00141-0.View ArticleGoogle Scholar
- Brinkman WB, Geraghty SR, Lanphear BP, Khoury JC, Gonzalez del Rey JA, Dewitt TG, Britto MT: Effect of multisource feedback on resident communication skills and professionalism: a randomized controlled trial. Arch Pediatr Adolesc Med. 2007, 161: 44-49. 10.1001/archpedi.161.1.44.View ArticleGoogle Scholar
- Wood J, Collins J, Burnside ES, Albanese MA, Propeck PA, Kelcz F, Spilde JM, Schmaltz LM: Patient, faculty, and self-assessment of radiology resident performance: a 360-degree method of measuring professionalism and interpersonal/communication skills. Acad Radiol. 2004, 11: 931-939.Google Scholar
- Patient and Physician Peer Assessment Module. [http://www.abim.org/pdf/pim-related/parpsq.pdf]
- Ginsburg S, Regehr G, Hatala R, McNaughton N, Frohna A, Hodges B, Lingard L, Stern D: Context, conflict, and resolution: a new conceptual framework for evaluating professionalism. Acad Med. 2000, 75: S6-S11. 10.1097/00001888-200010001-00003.View ArticleGoogle Scholar
- Minter RM, Gruppen LD, Napolitano KS, Gauger PG: Gender differences in the self-assessment of surgical residents. Am J Surg. 2005, 189: 647-650. 10.1016/j.amjsurg.2004.11.035.View ArticleGoogle Scholar
- Smith DK, Shaw RW, Slack J, Marteau TM: Training obstetricians and midwives to present screening tests: evaluation of two brief interventions. Prenat Diagn. 1995, 15: 317-324. 10.1002/pd.1970150404.View ArticleGoogle Scholar
- Marteau TM, Humphrey C, Matoon G, Kidd J, Lloyd M, Horder J: Factors influencing the communication skills of first-year clinical medical students. Med Educ. 1991, 25: 127-134. 10.1111/j.1365-2923.1991.tb00038.x.View ArticleGoogle Scholar
- Holm U, Aspegren K: Pedagogical methods and affect tolerance in medical students. Med Educ. 1999, 33: 14-18. 10.1046/j.1365-2923.1999.00332.x.View ArticleGoogle Scholar
- Holm U: The affect reading scale: a method of measuring the prerequisites for empathy. Scandinavian Journal of Educational Research. 1996, 40: 239-253. 10.1080/0031383960400304.View ArticleGoogle Scholar
- Roter DL, Hall JA, Aoki Y: Physician gender effects in medical communication: a meta-analytic review. JAMA. 2002, 288: 756-764. 10.1001/jama.288.6.756.View ArticleGoogle Scholar
- van Zanten M, Boulet JR, McKinley DW, DeChamplain A, Jobe AC: Assessing the communication and interpersonal skills of graduates of international medical schools as part of the United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills (CS) Exam. Acad Med. 2007, 82: S65-68.View ArticleGoogle Scholar
- Mumford E, Schlesinger HJ, Glass GV: The effect of psychological intervention on recovery from surgery and heart attacks: an analysis of the literature. Am J Public Health. 1982, 72: 141-151. 10.2105/AJPH.72.2.141.View ArticleGoogle Scholar
- Melamed BG, Siegal L: Behavioural medicine. Practical applications in health care. 1980, New York: SpringerGoogle Scholar
- Meyer TJ, Mark MM: Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol. 1995, 14: 101-108. 10.1037/0278-6220.127.116.11.View ArticleGoogle Scholar
- Stern D: Outside the classroom: teaching and evaluating future physicians. Spec Law Dig Health Care Law. 2006, 9-42.Google Scholar
- Swick HM, Szenas P, Danoff D, Whitcomb ME: Teaching professionalism in undergraduate medical education. JAMA. 1999, 282: 830-832. 10.1001/jama.282.9.830.View ArticleGoogle Scholar
- Veloski JJ, Fields SK, Boex JR, Blank LL: Measuring professionalism: a review of studies with instruments reported in the literature between 1982 and 2002. Acad Med. 2005, 80: 366-370. 10.1097/00001888-200504000-00014.View ArticleGoogle Scholar
- Ainsworth MA, Szauter KM: Medical student professionalism: are we measuring the right behaviors? A comparison of professional lapses by students and physicians. Acad Med. 2006, 81: S83-86. 10.1097/00001888-200610001-00021.View ArticleGoogle Scholar
- Arnold EL, Blank LL, Race KE, Cipparrone N: Can professionalism be measured? The development of a scale for use in the medical environment. Acad Med. 1998, 73: 1119-1121. 10.1097/00001888-199810000-00025.View ArticleGoogle Scholar
- Shue CK, Arnold L, Stern DT: Maximizing participation in peer assessment of professionalism: the students speak. Acad Med. 2005, 80: S1-5. 10.1097/00001888-200510001-00004.View ArticleGoogle Scholar
- Hassett JM, Zinnerstrom K, Nawotniak RH, Schimpfhauser F, Dayton MT: Utilization of standardized patients to evaluate clinical and interpersonal skills of surgical residents. Surgery. 2006, 140: 633-638. 10.1016/j.surg.2006.07.014. discussion 638–639View ArticleGoogle Scholar
- Buss MK, Alexander GC, Switzer GE, Arnold RM: Assessing competence of residents to discuss end-of-life issues. J Palliat Med. 2005, 8: 363-371. 10.1089/jpm.2005.8.363.View ArticleGoogle Scholar
- Boud D, Keogh R, Walker D: Promoting reflection in learning: a model. Reflection: Turning Experience Into Learning. Edited by: Boud D, Keogh R, Walker D. 1985, London: Kogan PageGoogle Scholar
- Gibbs G: Improving the Quality of Student Learning. 1992, Bristol: Technical and Educational ServicesGoogle Scholar
- Sobral DT: An appraisal of medical students' reflection-in-learning. Med Educ. 2000, 34: 182-187. 10.1046/j.1365-2923.2000.00473.x.View ArticleGoogle Scholar
- Mitchell R: The development of the cognitive behaviour survey to assess medical student learning. Teach Learn Med. 1994, 6: 161-167.View ArticleGoogle Scholar
- Hammond M, Collins R: Self-Directed Learning in Practice. 1991, London: Kogan PageGoogle Scholar
- Boekaerts M: Self-regulated learning: a new concept embraced by researchers, policy makers, educators, teachers, and students. Learning Instruction. 1997, 7: 161-186. 10.1016/S0959-4752(96)00015-1.View ArticleGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/9/1/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.