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Building physicians with self-awareness.

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Learn how three residency training programs used personality assessment--and shared the results with the participants--to assess and facilitate leadership development in orthopedic surgery.

THERE IS A NEW EMPHASIS ON THE NONTECHNICAL skills, including leadership, required to be a successful orthopedic surgeon. These skills have been codified in the educational structures created by the Accreditation Council for Graduate Medical Education, including the six domains of general physician competency and 41 milestones for orthopedic surgery. (1,2,3) Half of the six general competencies--systems-based practice, professionalism, and interpersonal and communication skills--do not involve technical proficiency. Likewise for seven of the 41 developmental milestones for orthopedic surgery.

Equivalent to the manner in which technical skills are assessed, nontechnical skills are evaluated on a modified Dreyfus scale, from 1 (novice) to 5 (expert). (4)

Within the systems-based practice domain, expert surgeons are system-change agents at various levels within their practice, ranging from the operating room to team management and patient flow across cases, and also lead quality improvement at local and regional levels.

In the interpersonal/communication skills domain, expert orthopedic surgeons are expected to coach others in communication skills and to reflect on improving their own skills in this area. At levels 3-5, surgeons are expected to understand their role as leaders of the OR team, including how to lead daily rounds and communicate plans of action to the OR team, lead team-based care, aspire to leadership opportunities within professional organizations, and orchestrate and/ or facilitate meetings.

For the professionalism domain, expert surgeons demonstrate leadership and mentor others in the principles of bioethics--having compassion, respect and integrity, and prioritizing responsiveness to a diverse population of patients over self-interest. (1) The ACGME's goal is for residents to earn level 4 expertise in each competency area by graduation, although no specific requirements for achieving this objective have been issued. As such, this decision is ultimately left up to individual programs and their clinical competency committees.

Failure of leadership was frequently cited as the underlying cause of unanticipated adverse events, such as patient mortality, in a recent report by the Joint Commission. (5) For this reason, the importance of effective leadership skills cannot be underestimated. To improve patient safety, it has been acknowledged that authoritative, surgeon-driven behaviors need to evolve into contemporary, team-oriented, facilitative leader behaviors that involve delegation and collaboration. (6) Furthermore, evaluating the effectiveness of the American Academy of Orthopaedic Surgeons Leadership Fellows Program has received increased attention among researchers. (7)

Leadership and leadership development clearly are important in orthopedic surgery. Yet, there is still a great need for integrated training programs at the post-graduate residency level that include the identification of residents with the motivation to lead in conjunction with the nurturing of these skills via courses and exposure to successful mentors. (8)

Within the medical field, researchers have begun to assess leadership skills among surgeons in OR teams. (9) These skills also have been found to predict positive performance outcomes in anesthesiology teams. (10) Research indicates that leadership development programs can help advance leadership behaviors among trainees, (11,12,13) subsequently resulting in positive performance. (14,15) The effectiveness of these leadership development experiences can be affected by the personality characteristics of trainees. (16) Additionally, prior research has investigated the characteristics of highly successful surgeons (17) and noted that personality characteristics are pertinent to successful surgical resident performance. (18,19) For this reason, personality assessment might have implications for leadership development initiatives. (20)

Researchers also have started to examine the relationship between self-awareness and leadership development. For instance, previous professional development programs for surgeons, pharmacy residents, nurses and physicians have, to varying degrees, incorporated assessments of trainee self-awareness. (21,22,23,24) Self-awareness, as it pertains to one's areas of challenge, has been linked closely to leadership effectiveness. (25) Therefore, greater self-awareness might be important for developing and/or improving leadership skills, as well as for adjusting the leadership styles of senior-level residents or surgeons to be most effective for more junior trainees.

Given the need for leadership development among orthopedic surgical residents and the key roles of personality and self-awareness in leadership development, we introduced these concepts to 76 residents at three institutions --25 residents at Rush University in Illinois, 20 residents at Harbor-UCLA Medical Center in California, and 31 residents at Cleveland Clinic in Ohio--as a novel orthopedic residency training protocol during the 2015-16 academic year.

This protocol has been successfully introduced at other orthopedic surgery residency programs and is believed to have the potential to improve mentoring relationships. (26) To assess residents' reactions, we surveyed their voluntary feedback about the training. Overall, the present commentary aims to describe our experience with using personality assessment to enhance the professional development of our residents.


Before the training session at each institution, each participant was emailed a link through a proprietary web-based portal by J3Personica of Eatontown, New Jersey, to complete three personality measures:

* The Hogan Personality Inventory, (24) which assesses typical interpersonal behavioral tendencies.

* The Hogan Development Survey, (27) which evaluates interpersonal behavioral tendencies when under stress.

* The Motives, Values, Preferences Inventory, (28) which measures the motives and values that drive performance.

The assessments were customized for use with orthopedic surgery residents by Residency Select, a product of J3Personica that uses psychometric assessment to help suitably pair residency programs and applicants.

On the day of the training session, residents received confidential copies of their personalized data reports from the three assessments. During the training session, a 45-minute explanation of the survey and its use was provided. Residents also were instructed on how to interpret their individual results. In addition, Residency Select/J3Personica provided each resident with a "Transition to Practice" guide containing suggestions for improving performance, which was tailored to each resident's personality assessment results.

Within 48 hours after the training, a survey was sent to residents via the online survey site Zoho to request their feed-back. Residents were asked to respond to four items, such as the extent to which they agreed that "The information in the presentation was useful to me" and "What specific aspect(s) of the presentation did you enjoy and/or find to be useful to you?" Fifteen residents across the three institutions responded to our survey.


Almost all residents who provided feedback concurred that the information in the presentation was relevant (93 percent, or 14 respondents) and that the information was useful (87 percent, 13 respondents). Comments indicating interest and relevance included, "I liked to see how my profile compared to other orthopedic residents and to my own fellow residents at our institution." Another resident mentioned "stress behaviors to be aware of so I can anticipate better," referring to the enhanced self-awareness of stress-related interpersonal tendencies. Although the response rate for this informal survey was relatively low, most residents who provided feedback reported having a favorable impression of the practicality and applicability of the training.

The lead author of this report, a Cleveland Clinic resident, says: "This formal assessment helped me to understand some of my unproductive tendencies while being stressed, as well as my idiosyncrasies, and has made me more aware of my behaviors," she says. "After learning the results of my personality profile, I realized that my underlying tendencies are to be overly self-critical and to put interpersonal skills on the backburner when there is an issue requiring my immediate attention. However, instead of interpreting these stress tendencies as weaknesses, the 'Transition to Practice' guide suggested ways to address these aspects of my personality to be a more effective communicator and leader, both during my residency training and in my future practice as an orthopedic surgeon."

Another co-author, a Rush University faculty member, concurs: "I recall a resident's noteworthy finding about a tendency to lack organization with regards to study habits. The resident agreed with the assessment results and acknowledged that the difficulties encountered in trying to study and in focusing while doing so were likely due to this absence of structure," he says. "The insights into this resident's tendencies allowed us to work together to develop an organized reading list for each rotation, starting with the intern year, which typically has the least structured requirements."

Another co-author, a Cleveland Clinic faculty member, echoes residents' perceptions about the relevance and usefulness of the training protocol: "Current orthopedic residents clearly understand the importance of teamwork for providing the best patient care," he says. "Several residents commented to me that the proverbial light bulb lit when they realized how they could accomplish their patient care goals more easily and efficiently by playing to their strengths and working on their weaknesses when collaborating with each other, as well as with the physician assistants, nurses and techs. A number of my residents provided anecdotes, where they had channeled their new insights into a situation that previously would have been, shall we say, tense. I look forward to the residents and their mentors using this information to improve resident performance."

As further noted by another co-author, a member of the Harbor-UCLA Medical Center faculty: "Residents' engagement continued undiminished in intensity throughout the duration of the formal training program, as very clear explanations of how individual results should be interpreted and how this information can be applied positively to advance their growth and development as leaders, were reviewed," he says. "Particularly valuable was the use of anecdotal and case-based illustrations to clearly explain how too much of an attribute, otherwise viewed as positive, can adversely influence effective leadership. Similarly, these training tools clearly explained how knowledge and awareness of one's own less desirable characteristics can be positively applied when appropriate for the situation and, in other circumstances, can be modulated or controlled to reduce the potential for unwanted adverse effects on interpersonal interactions that may compromise effective leadership.

"While it is clear that the personality of each resident is unique, knowledge of the individual assessment findings by each resident empowers them to alter their behavior in ways that allow them to function as more effective leaders. Aggregated information from these orthopedic-targeted personality assessment tools is extremely valuable to me as a program director in better understanding the collective personality of our program. Yet, it is also very interesting to see how similar or dissimilar we are in the various assessment domains, compared to other participating institutions with different faculty and unique training-related environmental pressures."

We strongly believe that as we gain more competence and expertise in administering and evaluating a targeted orthopedic leadership development program, our collective experience will be invaluable in serving as a model to guide other residency training programs in meeting ACGME core competencies and orthopedic surgery milestones. More important, however, such a development program will help us to be better equipped to prepare our graduates to achieve success in their professional and personal lives by optimally applying and mitigating the personality characteristics unique to them. As educators, this represents one of our greatest challenges, as we contribute to shaping the future generations of orthopedic surgeons.

Rachel M. Randall, MD, is a senior orthopedic resident at the Cleveland Clinic in Ohio.

Louis M. Kwong, MD, FACS, is professor and chairman of the orthopedic surgery department at Harbor-UCLA Medical Center in California, where he also is program director of orthopedic residency training and chief of joint replacement service.

Brett Levine, MD, MS, is an associate professor at Rush University Medical Center and adult reconstruction service line director at Elmhurst Memorial Hospital Center, both in Illinois. He is the former residency and student clerkship director at RUMC.

Monica Kogan, MD, is an assistant professor in orthopedic surgery and is the orthopedic surgery residency director at Rush University Medical Center in Illinois. She specializes in pediatric orthopedic surgery.

Thomas E. Kuivila, MD, is vice chair for education in the Orthopedic and Rheumatologie Institute and residency program director in the orthopedic surgery department at Cleveland Clinic in Ohio.


(1.) ACGME & AB05. The Orthopaedic Surgery Milestone Project.; 2015. acgme. org/acgmeweb/portals/O/pdfs/milestones/orthopaedicsurgerymilestones.pdf.

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(3.) Stern PJ, Albanese S, Bostrom M, et al. Orthopaedic Surgery Milestones. J Grad Med Educ. 2013;5(1 Suppl 1):36-58. doi:10.4300/JGME-05-01s1-05.

(4.) Brigham T. Getting ready for residency: Competencies, the Next Accreditation System and you. October 2013. acceleratingchange/pdf/getting-ready-for-residency-brigham.pdf. Accessed March 11, 2016.

(5.) Joint Commission. Sentinel Event Data: Root Causes by Event Type. The Joint Commission; 2015. Event_Type_2004-3Q_2015.pdf. Accessed March 11, 2016.

(6.) Kuo C, Robb W. "Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety." Clin Orthop. 2013;471(6):1792-1800. doi:10.1007/s11999-012-2719-3.

(7.) Day CS, Tabrizi S, Kramer J, Yule AC, Ahn BS. "Effectiveness of the AA0S Leadership Fellows Program for orthopaedic surgeons." J Bone It Surg. 2010;92(16):2700-2708. doi:10.2106/JBJS.J.00272.

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(28.) Hogan J, Hogan R. Motives, Values, Preferences Inventory Manual, Tulsa, OK; 2010.


1. Systems-Based Practice

Within orthopedic surgery milestones, a top leader drives systems change at the micro and macro level and local or regional quality improvement projects. Also, uses technology to deliver safe health care.

2. Medical Knowledge

Within orthopedic surgery milestones, physicians should be familiar with 16 specific maladies.

3. Professionalism

Within orthopedic surgery milestones, physicians should maintain compassion, integrity and respect for others, sensitivity and responsiveness to diverse patient populations, and accountability to others.

4. Patient Care

Within orthopedic surgery milestones, physicians should be familiar with 16 specific maladies.

5. Interpersonal and Communication Skills

Within orthopedic surgery milestones, a top leader demonstrates leadership by coaching others, works on improving his/her own skills, and seeks leadership opportunities within professional organizations.

6. Practice-Based Learning and Improvement

Within orthopedic surgery milestones, physicians engage in self-directed learning to identify strengths, deficiencies and limits; assess patient outcomes; set improvement goals; use technology to optimize learning and improve outcomes; and locate, appraise and assimilate scientific evidence to improve patient care.

Sources: Accreditation Council for Graduate Medical Education, American Board of Orthopaedic Surgery.

Caption: Researchers are exploring the relationship between self-awareness and leadership development. The theory is that self-awareness is linked closely to leadership effectiveness--especially for senior-level residents and surgeons to be most effective for their trainees.
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Title Annotation:LEADERSHIP
Author:Randall, Rachel M.; Kwong, Louis; Kuivila, Thomas; Levine, Brett; Kogan, Monica
Publication:Physician Leadership Journal
Date:May 1, 2017
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