An ophthalmology professionalism survey tool: Outcomes from a multi-center study in Central India
This was a multi-center survey study conducted in Central India. The study protocol was approved by the Institutional Review Board at Sadguru Netra Chikitsalaya (in Chitrakoot). Electronic informed consent was obtained from all participants. The 33-question scenario-based survey was developed using the 29 essential and 4 non-essential professionalism attributes previously identified by Chandratilake et al . The attributes were grouped into four broad categories ; “personal characteristics,” “physician–patient relationship,” “workplace practice and relationship,” and “socially responsible behaviors.” Each attribute had one case-based scenario. All questions had four response options: unacceptable, probably unacceptable, probably acceptable, and acceptable. The survey was based on a previously validated scenario-based survey tool used by Alkahtani et al . to evaluate medical professionalism in ophthalmology in Saudi Arabia. The survey language was slightly modified for grammar and spelling, and shortened to 33 questions with only 1 scenario-based question per professionalism attribute. The modified survey tool was validated using the Delphi method by 10 US-based ophthalmologists in active practice at an academic institution in Chicago, IL. The validated 33-question survey was then content screened for cultural differences by six ophthalmology experts in India, which consisted of senior ophthalmology consultants in active practice with at least 1 year of fellowship training. The final survey tool can be found in the . An expert panel was assembled from the six most senior Indian ophthalmology consultants in active practice, selected from the institutions participating in the survey. The Indian ophthalmology experts discussed all 33 scenario-based questions in roundtable discussions, and a consensus was reached for one correct answer to each question, which was designated as the “gold-standard” answer. The anonymized survey was then administered online (www.qualtrics.com) to junior residents, senior residents, fellows, and consults across five institutions in Central India. A junior resident was defined as a physician pursuing post-graduate medical education in ophthalmology. A senior resident was defined as a physician who has recently completed postgraduate medical education in ophthalmology, is not currently pursuing specialty training, but is continuing to work in the hospital with resident duties. A fellow was defined as a physician who finished postgraduate training in ophthalmology and was pursuing post-residency specialty training. A consultant was defined as a senior physician who has completed all their specialty training. The 5 participating institutions were Sadguru Netra Chikitsalaya (Chitrakoot), Ghandi Medical College (Bhopal), Shyam Shah Medical College (Rewa), Gahra Raja Medical College (Gwalior), and Sardar Patel Medical College (Bikaner). All five institutions were accredited for postgraduate ophthalmic education. None of the institutions provided formal instruction in professionalism. The survey was structured with a forced-answer function so that only 100% of completed survey responses were eligible for submission. The responses were analyzed similarly to the analysis performed by Alkahtani et al . The responses collected from each survey participant were grouped into two categories to simplify the analysis (category 1 = unacceptable + probably unacceptable; category 2 = acceptable + probably acceptable). These responses were then compared to the expert panel’s gold standard answers for each question and coded as “1” if in agreement or “0” if not. The sum, or total attribute score, for each participant, was then calculated. The mean attribute score was then calculated for each participant as follows: Mean attribute score = Total attribute score/total questions completed A higher mean attribute score indicated that the responses of the participant were closer to the consensus of the expert panel. Statistical Package for Social Sciences (SPSS 23 IBM, NY, USA) was used for analysis. Nonparametric tools were used to detect differences in the attribute score of respondents compared to the expert group for each category and for each attribute group. Results were presented in frequencies and percentage proportions for three groups (consultants, residents, and fellows) and were compared using the Chi-square test with a 5% level of statistical significance. Descriptive statistics were calculated, and correlation analysis was performed. The scores among three groups (consultants, fellows, and residents) were compared with the Freedman test at 5% level of significance. Additional pairwise comparisons were performed using non-parametric Mann–Whitney U test using a 5% level of statistical significance.   The survey was completed by 225 participants: 124 residents, 47 fellows, and 54 consultants. Survey participant demographics are described in . The majority of participants (43.7%) were from Institution 1. Residents in-training accounted for 50.6% of participants. The majority of participants were female (54.3%, P = 0.018). The mean attribute score for all participants in the survey was 80.7 ± 9.1 (min 16.67, max 100). The scores were significantly different among the four attribute groups ( P < 0.001). The mean attribute scores for all participants were the highest for “personal characteristics” (93.1 ± 9.7) and “physician–patient relationships” (82 ± 15.8), and lowest for “workplace practice and relationships” (72.4 ± 13.1) and “socially responsible behaviors (73.9 ± 18.6). The mean attribute scores by attribute group for residents, fellows, and consultants are described in . There was a trend toward higher mean attribute scores for consultants compared to trainees across all attribute groups. This trend did not reach statistical significance for “personal characteristics,” “physician–patient relationship,” or “workplace practice and relationship.” For “socially responsible behavior,” there was a statistically significant variation in attribute score among the four groups of participants, with consultants scoring significantly higher than trainees ( P < 0.05). There was no significant difference in attribute score by the institution ( P = 0.114) or participant gender ( P = 0.102).   Professionalism is a core competency of medical training and is a fundamental aspect of quality patient care. However, it is difficult to teach and quantify using a standardized approach. Lynch et al . and Lee et al . have previously reviewed the literature on teaching and assessing professionalism, and have emphasized the importance of the development of standardized tools to evaluate professionalism in multi-center studies. In our study, we used 35 professionalism attributes identified with global consensus by Chandratilake et al . as a tool to assess knowledge of professionalism across FIVE institutions in central India. For standardization purposes, we addressed the professionalism attributes using a scenario-based survey similar to the one used by Alkahtani et al. , which was used to evaluate professionalism in ophthalmology in Saudi Arabia, with the differences discussed below. To our knowledge, this is the first study on medical professionalism in ophthalmology in India. The ultimate goal of this study is to use this validated professionalism survey tool in conjunction with other methods to assess professionalism for the initiation of case discussions around medical professionalism and teaching of professionalism in ophthalmology. In our study, we had responses from 225 physicians with an exceptional response rate of 98.4%. In comparison, the Saudi Arabia study had only 147 participants and a response rate of 94.8%. There was no significant difference in response rate in the two studies. The multi-center nature of our study was a major difference between our study and the Saudi study (single-site study). The majority of our participants came from Institution 1 (43.7%), which is the largest institution surveyed and the largest rural eye care provider in India. Institution 1 serves more than a million patients annually, and has more than 100 full-time ophthalmologists. The response rate from Institution 1 (100%) was among the highest in this study, along with Institution 4, which also had a response rate of 100%. The variability in response rate among the institutions was minimal and did not significantly affect the outcomes of this study. The survey tool used in this study was similar to the previously validated survey tool developed by Alkahtani et al. , but also addresses some of that study’s limitations. Instead of 51 scenario-based questions we elected to include only 33 scenario-based questions with a single question for each attribute (29 essential attributes and 4 non-essential attributes were tested). “Personal well-being of the doctor” was a non-essential attribute group and was cut from the survey by our expert panel to keep the survey to a shorter, more manageable length. Alkahtani et al. , in their publication, recommended that future studies that utilized the survey should revisit the categorization of questions because it is subjective and may be influenced by regional opinion. Therefore, the “gold standard” responses were reassessed by a local expert panel in India and the survey questions were re-categorized to the attribute groups (as shown in ). The survey language was also slightly modified for grammatical differences. We found that knowledge of medical professionalism as assessed by this survey tool was generally high in ophthalmology training centers in Central India. The mean attribute score for all participants in the survey was 80.7 ± 9.1 (min 16.67, max 100). In comparison, the mean attribute score in the Saudi study was 84.1 ± 10.1. Given that these are the only two studies using this standardized tool to assess professionalism, it is difficult to further compare the results of this study to other studies assessing professionalism across other medical specialties. Overall, the mean attribute score of all participants in this study was similar to the mean attribute score found by Alkahtani’s study in Saudi Arabia, which helped to validate the survey tool. There are potential differences in cultural perceptions regarding medical professionalism in different countries; thus, this study should be replicated at other institutions through multi-center studies around the world. Importantly, the present study assessed knowledge of professionalism among five accredited training institutions. The results should be interpreted in this context only. As previous studies have shown, training in India has a history of being quite variable. Our results should be extrapolated with caution to non-accredited training institutions and private sector physicians. There is still a lack of data from ophthalmologists in the private sector in India. Ophthalmic societies in India should conduct studies on professionalism to include data from physicians in the private sector. Professionalism is a critical competency at all levels of a medical career. Residents play an especially important role because they are often the first practitioner the patient encounters in an academic setting. Residents also spend a lot of time with medical students, who often look up to them as role models. A recent study by Alghulaydhawi et al . evaluated professionalism in ophthalmology among junior and senior residents-in-training in Saudi Arabia. They found scores between junior and senior residents were significantly different, with the senior residents scoring overall higher than the junior residents. In our study, the majority of responders were junior residents-in-training (46.5%). Senior residents accounted for only 4.1%. As previously defined, a senior resident was a physician who has recently completed post graduate medical education in ophthalmology, is not currently pursuing specialty training, but is continuing to work in the hospital with resident duties. The majority of junior residents either go on to do a fellowship or begin to work as a consultant; thus the number of senior residents was low. We included this group of physicians for completeness to assess professionalism at all stages of a career in ophthalmology in India. Thus, comparing our results with senior residents-in-training to other trainees-in-training should be performed with caution. Notably, the mean attribute score for consultant participants was lower than the expert consensus group (83.4 vs. 100). It is difficult to compare the two groups because of the setting in which the survey was completed. The expert consensus group was given time for round-table discussion for each question to allow the experts more time to weigh in on each question and thus come to a single consensus answer (gold standard answer). Consultants participating in this web-based survey independently may be less inclined to give each scenario-based question similar in-depth thought and attention. Additionally, there may also be differences in responses from junior versus senior consultants; participating junior consultants may be more tech-savvy, whereas senior consults may be less inclined to attentively participate in a web-based survey. In this study, we found variation in the mean attribute score by professionalism attribute ( P < 0.001), specifically the mean attribute scores were the highest for “personal characteristics” and “physician–patient relationships,’ and the lowest for “workplace practice and relationships” and “socially responsible behaviors.” “Personal characteristics” such as honesty, integrity, and reflective practice are core competencies inherent to persons in the medical field. This is not to say that these professionalism attributes cannot be learned, but generally they appear to naturally “high” among physicians both in our study and in the Saudi study. Attributes related to the “physician-patient relationship,” such as respect for patients’ autonomy and confidentiality, are also naturally “high” perhaps because these are competencies often taught through didactics and observations very early in medical education. In contrast, attributes relating to “workplace practices” are learned through experience and leadership development programs. Thus, the low scores for “workplace practices” may represent a lack of professional development practices and limited education regarding professional rules and regulations. Similarly, attributes related to “socially responsible behaviors,” such as making effective use of resources, are highly influenced by experience and continuing education. Overall, the potential for improvement in professionalism exists in workplace practices and socially responsible behaviors related to the practice of ophthalmology in India. Studies on medical professionalism are important to conduct because all physicians being human can drift out of compliance with professionalism competency. Many factors can contribute to this, including time pressures and psychosocial stressors. In this study, there was a trend toward high mean attribute scores among those with higher levels of training or experience (although this difference was not statistically significant except for “socially responsible behavior”). For “socially responsible behavior,” consultants scored significantly higher than trainees ( P < 0.05). Attributes that fall under “socially responsible behavior” include “making effective use of available resources” and “adhering to professional rules and regulations,” which come with experience as a practicing physician. Alkhatani et al . also found higher mean attribute scores among consultants than trainees. This may be explained by experiential learning of professionalism and has been also been reported among pediatricians in a survey of pediatric program directors in the United States. There may also be generational-based attitude differences among consultants and trainees regarding “socially responsible behavior” that has led to a greater difference between the two groups. Importantly, although the difference between trainees and consultants was statistically significant, results were still high for both (trainees average attribute score 71.5 vs. 80.1 for consults) and not influenced by institution. Future studies should attempt to evenly distribute the number of questions for each attribute group; in our study, we had 13 questions for “personal characteristics” and only six questions for “socially responsible behaviors.” Evenly distributed attribute groups would allow for better statistical comparison between groups. Importantly, the goal of this survey was not to “quantify” an absolute score for the level of professionalism, but more so to highlight any differences in knowledge of professionalism at different levels of training and experience. Although consultant physicians scored higher on this survey tool, it does imply that they practice this level of professionalism in real life. One drawback of survey tools is that they can be used to assess knowledge in professionalism competency, but they do not teach professionalism. Therefore, the authors strongly recommend the use of this professionalism survey tool not just as an evaluation tool but more importantly as an educational tool by doing a debrief session with all participants to discuss appropriate versus inappropriate responses to each scenario-based question. As was shown by Khan et al. , residents in ophthalmology modified their perception of professionalism after discussion of professionalism vignettes with their program director. Furthermore, the residents thought the exercise was useful and promoted self-reflection, which is key for professionalism development. Ultimately, the scores are not as important as the discussion around this survey tool. This tool can serve to initiate important discussions about different attributes of professionalism, it can raise awareness regarding unprofessional behavior, and it can be used to teach medical professionalism to ophthalmologists and ophthalmologists-in-training. In summary, this study developed and validated a professionalism survey tool, which was used to assess professionalism knowledge in training programs in Central India. We found that knowledge of professionalism competency was generally high; however, there were discernable differences in the level of training and experience. In general, consultants scored higher than trainees, which means that they know the answers better but does not necessarily mean that they practice this level of professionalism in real life. We suggest that this survey tool be used in conjunction with other methods of professionalism competency assessment, such as observation, mentorship, and multisource feedback. Furthermore, this survey tool can serve as a valuable discussion starter and teaching tool to enhance professionalism in ophthalmology. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.   Nil.   There are no conflicts of interest.   