ORIGINAL ARTICLE

Pursuing Professional Accountability

An Evidence-Based Approach to Addressing Residents With Behavioral Problems
Hilary Sanfey, MB, BCh, MHPE; Debra A. DaRosa, PhD; Gerald B. Hickson, MD; Betsy Williams, PhD, MPH;
Ranjan Sudan, MD; Margaret L. Boehler, RN, MS; Mary E. Klingensmith, MD; Debra Klamen, MD, MHPE;
John D. Mellinger, MD; James C. Hebert, MD; Kerry M. Richard, Esq; Nicole K. Roberts, PhD;
Cathy J. Schwind, RN, MS; Reed G. Williams, PhD; Ajit K. Sachdeva, MD; Gary L. Dunnington, MD

Objective: To develop an evidence-based approach to Main Outcome Measures: Evidence-based strate-

the identification, prevention, and management of sur- gies for the identification, prevention, and management
gical residents with behavioral problems. of problem residents.

Design: The American College of Surgeons and South-
ern Illinois University Department of Surgery hosted a
1-day think tank to develop strategies for early identifi-
cation of problem residents and appropriate interven-
tions. Participants read a selection of relevant literature
before the meeting and reviewed case reports.
Setting: American College of Surgeons headquarters,
Chicago, Illinois.
Participants: Medical and nursing leaders in the field
of resident education; individuals with expertise in
dealing with academic law, mental health issues, learn-
ing deficiencies, and disruptive physicians; and surgical
residents.
Results: Recommendations based on the literature and
expert opinions have been made for the identification,
remediation, and reassessment of problem residents.
Conclusions: It is essential to set clear expectations for
professional behavior with faculty and residents. A notice
of deficiency should define the expected acceptable behav-
ior, timeline for improvement, and consequences for non-
compliance. Faculty should note and address systems prob-
lems that unintentionally reinforce and thus enable
unprofessional behavior. Complaints, particularly by new
residents, should be investigated and addressed promptly
through a process that is transparent, fair, and reasonable.
The importance of early intervention is emphasized.
Arch Surg. 2012;147(7):642-647

Author Affiliations are listed at
the end of this article.
A
PROBLEM RESIDENT (PR) IS
“one who fails to meet the
standard of performance in
one or more Accredita-
tion Council for Gradu-
ate Medical Education (ACGME) compe-
tency.” 1(p201) Such residents consume
substantial program director (PD) and staff
time, adversely affect patient care, and dis-
rupt team function.2,3 Deficits may exist in
See Invited Critique
at end of article
all core competencies; this article focuses
on the resident with behavioral prob-
lems. This is defined by the American
Medical Association3 as “personal con-
duct, whether verbal or physical, that nega-
tively affects or potentially affects patient
care including conduct that interferes with
one’s ability to work with members of a
health care team” and by The Joint Com-
mission as behavior that undermines a cul-
ture of safety.4 This behavior includes ver-
bal outbursts, physical threats, refusing to
perform tasks, or exhibiting an uncoop-
erative attitude. Institutional leaders are
required to have policies that address such
CME available online at
www.jamaarchivescme.com
behaviors whether caused by impair-
ment due to substance abuse or other psy-
chiatric disorder, external life stressors,
personality characteristics, lack of train-
ing, or system factors.
Although disruptive physicians con-
sume considerable attention, 50% of the
concerns are associated with only 9% to
14% of physicians.5 This minority is re-
sponsible for 50% of malpractice claims
costs.6 Preliminary results on a 360° instru-
ment assessing the core competencies sug-
gest that disruptive physicians may not dif-
fer significantly from other physicians in
mean performance but have an increased
frequency of low ratings (the tail of the
distribution is skewed). 7 In a single-

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 institution study,8 25% of residents, who graduated on time
and passed the American Board of Surgery examinations
on the first attempt, received marginal performance evalu-
ations. Nationally, the cumulative risks of termination are
3.0% and 19.5%, respectively, for all surgical residents.9
Although many “voluntary” resignations may not be en-
tirely voluntary, there is still some discrepancy between
the 3% who are terminated and the reported prevalence
of PRs. Some of these residents might be successfully re-
mediated; however, it is likely that many graduate with-
out correction.
Identifying PRs is challenged by poorly defined stan-
dards for achievement of the ACGME competencies.10 Fur-
thermore, residents are employees who provide an es-
sential service; therefore, faculty are reluctant to increase
the workload on colleagues by removing a resident from
clinical duties. In addition, deficits in one domain may
be overlooked because of excellence in another. For ex-
ample, lapses in professionalism might be tolerated in the
surgical resident who is well liked and has excellent tech-
nical skills. Barriers to reporting a PR include lack of
knowledge as to what should be documented, concern
about an appeal process, lack of remediation options, and
a sense that nothing will change after reporting the be-
havior. Additional impediments include time restric-
tions, infrequent contact with the resident, and unfamil-
iarity with program expectations.11 Finally, faculty have
concerns about losing their role as resident advocate, how
these negative evaluations will be used, and retaliation
from the resident.2 Therefore, the evaluation informa-
tion available to the PD is often scanty or contradictory.
Although these behaviors are prevalent nationally, in-
dividual PDs will encounter PRs less frequently and can
experience conflict between their roles as resident advo-
cate and disciplinarian. In a 2009 literature review,12 only
2 studies13,14 addressing resident remedial interventions
were identified. Both addressed knowledge deficits. Sub-
sequently, 2 remediation programs have been described:
1 for radiology residents incorporating an educational
agreement with the resident, PD, and a faculty educa-
tional liaison15 and another, more detailed approach for
emergency medicine residents.16 Torbeck and Canal17 found
that surgery PDs experience greater difficulty with reme-
diating professionalism, interpersonal communication, and
practice-based learning and improvement (PBLI) com-
pared with other ACGME competencies. To address this
need, the Southern Illinois University School of Medi-
cine Department of Surgery, in collaboration with the
American College of Surgeons, sponsored a 1-day think
tank to develop an evidence-based approach to the iden-
tification, prevention, and management of PRs. The in-
vited participants included residents, medical and nurs-
ing leaders in the field of resident education, and individuals
with expertise in dealing with academic law, mental health
issues, learning deficiencies, and disruptive physicians.
METHODS
The 2011 meeting took place at the American College of Sur-
geons offices in Chicago, Illinois. Attendees read relevant litera-
ture before the meeting and participated in short didactics on
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institutional and legal approaches to PRs. This was followed by
a brainstorming session using the nominal group technique to
identify potential strategies for remediating PRs. The nominal
group technique is a structured process for generating numer-
ous ideas.18 Two of us (N.K.R. and R.G.W.) prepared 2 cases
of PRs based on structured interviews conducted with surgery
PDs during their research.19 Both cases had characteristics found
in many PRs and were discussed in detail to elucidate com-
mon themes as a platform to making recommendations for
remediation.
RESULTS
Common findings were that both residents had ad-
vanced degrees on admission to residency training and
red flags in their application, that is, poor grades in 1 or
more clerkships, a US Medical Licensing Examination
score of 200 or less, and few glowing comments in let-
ters of recommendation. Both had concerns noted in the
first year of training. Paradoxically, each had a signifi-
cant percentage of end-of-rotation evaluations that were
better than the middle anchor “good.” In their programs,
only 5% of all resident ratings are at “good” or below. Both
PRs completed training on schedule. Hauer et al12 noted
that remediation begins with identification of the prob-
lem; is followed by remedial education, including the op-
portunity for feedback and reflection; and concludes with
a postintervention assessment. We used this framework
to propose remediation strategies based on what is known
from the literature and on the expert opinions.
RECOMMENDATIONS FOR EARLY
IDENTIFICATION AND PREVENTION
OF BEHAVIORAL PROBLEMS
The literature on early warning signs focuses predomi-
nantly on identifying knowledge deficits.8,12,13 Risk fac-
tors include applicant age older than 29 years, a need to
repeat medical school courses, and average grades on tran-
scripts.8,20 Medical schools wish to present their gradu-
ates in the best possible light; therefore, negative or neu-
tral comments in deans’ letters should be taken seriously.20,21
Transfer from another institution is also a risk factor for
subsequent behavioral problems. Recommendations to im-
prove the selection process include ensuring that each in-
stitution has a clear understanding of its culture and value
system so that candidates who match are a good fit. It is
also worth exploring social support, strategies for man-
aging time and for managing failure, and collaborative skills
during the applicant interview.22 The use of multiple mini-
interviews, provocative Objective Standardized Clinical Ex-
aminations,23 or personality testing was also suggested but
noted to be time-consuming. The meeting participants rec-
ommended getting input from residents and coordina-
tors to detect behaviors suppressed during faculty inter-
actions. Furthermore, providing the selection committee
with clear interview and ranking criteria will ensure con-
sistency and avoid capricious decisions. Clearly defined
processes are important, but equally important is their con-
sistent implementation. Finally, it is essential to be aware
of the effect of the hidden curriculum of attending role mod-
eling on resident behavior and to appreciate that it is un-
WWW.ARCHSURG.COM

Table 1. Adaptations From ACGME Common Program
Requirements for Resident Documentation
and Summative Evaluation28
Requirement
Resident documentation
V.A.1.a. Faculty evaluate resident performance in a
timely manner and document this
evaluation upon completion of the
assignment
V.A.1.b. 1. Provide objective assessments of
competence in all competencies
2. Use multiple evaluators
3. Document progressive resident
performance improvement and provide
feedback with documented semiannual
evaluation of performance
V.A.1.c. Ensure that evaluations are accessible for
review by the resident
Summative evaluation a
V.A.2.a. Document the resident’s performance
during the final period of education
V.A.2.b. Verify that the resident has demonstrated
sufficient competence to enter practice
without direct supervision
Abbreviations: ACGME, Accreditation Council for Graduate Medical
Education; V.A., section 5A.
a This evaluation becomes part of the resident’s permanent record
maintained by the institution and must be accessible for review by the resident
in accordance with institutional policy.
reasonable to hold residents to a higher standard of pro-
fessional behavior than their faculty mentors.
Because behavioral problems are frequently identi-
fied early in training,19,24 the first 6-month review is a time
for critical evaluation of new residents; indeed, there is a
case for conducting quarterly reviews of new residents.
Any problem arising at any time should be brought to
the attention of the PD for full investigation and a docu-
mented action plan with an end point for further evalu-
ation. In an internal medicine study,25 60% of PDs iden-
tified PRs through critical incident reports. In 75% of those
cases, PDs first became aware of PRs through verbal com-
plaints from faculty, and only 31% identified a PR from
a written evaluation.25 Thus, all notifications, regardless
of formality, are valuable in assessing the need for reme-
diation.26,27 Another consideration is that faculty mem-
bers with only occasional contact with residents tend to
be more generous with their ratings; thus, these ratings
need to be interpreted with caution. The differences be-
tween the detailed documentation required by the
ACGME28 (Table 1) compared with the minimum le-
gal requirement are discussed in the “Additional Legal
Considerations” subsection.
An effective, user-friendly evaluation system is essen-
tial to identify resident deficiencies. Evaluation should
include a review of all letters, e-mails, patient com-
plaints,24 and incident reports, as well as input from mul-
tiple team members.26,27 Setting up a confidential hotline
is another means of collecting data, but these are open
to abuse through retaliatory reporting. Effective evalu-
ation also includes setting standards to measure resi-
dent performance, providing rater training, and enforc-
ing consequences for not completing evaluations in a
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timely manner. Narratives are often more useful than nu-
meric ratings in identifying PRs.29 All evaluations should
be based on direct observation, but it should be acknowl-
edged that these will be subjective.30,31 While investigat-
ing clinical supervision practices, Kennedy et al32 iden-
tified 4 factors that affect supervisor perception of trainee
trustworthiness: knowledge/skill, discernment of limi-
tations, truthfulness, and conscientiousness. Two tech-
niques used to assess trustworthiness included double-
checking trainees’ clinical findings and identifying cues
from the trainees’ use of language. Language cues in-
cluded the structure of delivery during case presenta-
tions and the ability to anticipate needed information be-
fore it was solicited by the supervisor.32
Faculty development efforts aim to teach faculty the di-
mensions and elements of each competency and provide
instruction on frame of reference, rating errors, and the
importance of feedback.32 Because PBLI is essential for self-
improvement, evaluations should note the extent to which
residents take responsibility for their learning.33-35 Resi-
dents with a “growth” mind-set believe their success is based
on hard work and learning,33 while those deficient in PBLI
(“fixed” mind-set) attribute their success to innate ability
and their failures to the actions of others. The latter PRs
are a challenge to remediate. Problematic behavior can be
goal directed, for example, shouting, hanging up the phone
before a conversation has ended, or not responding to pages
so the nurses do not call again. Such behavior can cause
staff to misunderstand their role and provide services out-
of-scope, ultimately having a negative effect on the qual-
ity of health care.2,36 Recognizing and addressing such be-
havior through a system-level response will increase the
likelihood of successful remediation.
RECOMMENDATIONS FOR REMEDIATION
OF BEHAVIORAL PROBLEMS
Once a problem is suspected, the resident should be pro-
vided with a notice of deficiency that defines the ex-
pected acceptable behavior, the timeline for improve-
ment, and the consequences for noncompliance. He or
she needs to understand through self-reflection that such
behavior is unacceptable and detrimental to the resi-
dent, the program, and patients.27 The responsibility for
behavioral change rests with the resident, but the pro-
gram has an obligation to set clear expectations and sup-
ply appropriate surveillance, mentorship, and timely feed-
back. The Vanderbilt Promoting Professionalism Pyramid
for managing disruptive behavior is a useful approach.27
This model focuses on 4 graduated interventions: infor-
mal conversations for single incidents, nonpunitive aware-
ness interventions when data suggest patterns, leader-
developed action plans if patterns persist, and disciplinary
processes if the plans fail.27 This involves commitment
from the leadership to support the processes for review-
ing allegations and provide the leader training in con-
ducting the important conversations.5 Exempted from this
graduated process are egregious events consistent with
The Joint Commission’s Sentinel Event Alert.4
The Professional Renewal Center in Lawrence, Kan-
sas,2,7,36 provides assessment, treatment, and professional
development opportunities to trainees and practitioners
WWW.ARCHSURG.COM
 for issues of professionalism, interpersonal and commu-
nication skills, disruptive behavior, and psychiatric prob-
lems. This is accomplished through a multidisciplinary as-
sessment using standardized assessment instruments,
interviews, and collateral data collection. In the course of
the think tank, the center director (B.W.) emphasized that
understanding the behavior as well as its contributory fac-
tors and consequences is critical to providing the appro-
priate remediation. The director reported that practicing
physicians were more likely to be referred for substance
use or disruptive behavior; residents were more likely to
be referred for lack of timeliness, such as delinquency in
completing administrative duties that are disruptive to
health care team function. Residents had significantly more
deficiencies in PBLI than practitioners. In most circum-
stances, residents with behavioral problems did not have
personality disorders or impairment problems. Most pro-
fessionals, both in training and in practice, responded to
a tiered intervention approach. The meeting participants
identified additional remedial interventions; these are sum-
marized in Table 2.37
RECOMMENDATIONS FOR REASSESSMENT
OF BEHAVIORAL PROBLEMS
If self-reflection or remediation fails to achieve the de-
sired result, PDs must follow through on the previously
discussed consequences of probation, failure to promote,
or dismissal. Failure to enforce consequences has a nega-
tive effect on the behavior and morale of all residents and
the care delivery system. The best way to ensure that de-
cisions are not arbitrary or capricious is to use a clinical
competency committee. Problems are often identified in
committee discussions that are not raised by individu-
als,15,29,38 permitting the identification of patterns of be-
havior when an individual saw only a single instance. Such
committees serve as checks and balances, particularly in
identifying the marginal resident. Roberts and Williams39
suggest that committees consider whether the resident’s
performance can be improved sufficiently to perform ef-
fectively as a member of the health care team and whether
this improvement is likely to be sustained in practice as
well as during training. Other considerations are the cost
of remediation in time, effort, and resources, as well as the
hidden cost of retaining a resident in terms of the in-
creased workload on colleagues necessitated by “work-
arounds,” double-checking, and low morale. Finally, it is
essential to consider the effect on patient care and on a
patient’s perception of the health care team and institu-
tion.39 The meeting participants noted that the amount of
time spent discussing a resident is frequently a measure
of the severity of the problem.
Academic faculty are the gatekeepers of the profes-
sion, with a responsibility to assess resident competency
for independent practice.40 If standards are not met after
remediation, the faculty have a responsibility to dismiss
the resident. The ACGME requires that PDs complete a
final summative assessment of each resident.41 This should
be balanced and include any significant weaknesses or un-
remedied deficiencies in the core competencies, as well as
deficiencies that were successfully remediated. The pro-
gram must provide copies of a final assessment, consis-
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Table 2. Brainstorming Ideas for Remediation a
Idea Strategy
Reflection Encourage the problem resident to gain
insight into his or her behavior by
writing a reflective paper or
maintaining a journal to track thoughts
and emotions throughout the day
Increase self-awareness a. Interpersonal skill coaches used in
through external and the business world for problem
internal feedback: solicit executives or leaders might be in a
perspectives on how the position to objectively identify the
resident is viewed behaviors that lead others to view the
resident as arrogant, uncooperative,
or otherwise deficient
b. Additional feedback from nurses or
others with whom the resident works
might offer helpful insights into the
problem behaviors
c. Self-assessments over time could be
solicited during the intervention to
promote self-awareness
Systems analysis: a. Root cause analysis and discussion
identifying features among others in the residency
of residents’ work program can identify triggers in the
environment that may environment that may cause or
trigger unprofessional contribute to potential problem
behaviors behaviors
b. Ensure that the program director is
positioned in the hospital leadership
to affect practice change in the work
environment
Punitive consequences a. High concern or probation status
b. Required attendance at an outside
boot camp designed to help
remediate residents needing
professional interventions
Simulation activities a. Mock pages37
b. Residents role-play as patients to
heighten sensitivity and awareness;
debriefing would follow.
c. Videotaped role plays of problem
resident dealing with simulated
scenarios; debriefing would follow.
Structured mentoring a. Assign a senior resident as a mentor
with a clear “job description”
b. Assign a faculty mentor who meets
regularly with the resident
a Participants engaged in an open brainstorming session using the
nominal group technique to identify potential strategies for remediating
problem residents. Although several pages of ideas were identified, the 6
listed herein were the best, as voted by the attendees.
tent with what has been communicated to the resident,
to future employers on request. Finally, since an impor-
tant impediment to terminating a resident is the diffi-
culty of finding a qualified replacement, the meeting par-
ticipants suggested creating an agency for preliminaries
and a national ranking system for their evaluation.
ADDITIONAL LEGAL CONSIDERATIONS
The courts have unfailingly confirmed that as long as the
minimal process of Horowitz28 has been met, that is, the
individual was provided with “notice and an opportunity
to cure and the faculty decision is conscientious and de-
liberate,”28(p17) courts will not second-guess the academic
decision.42 Richard and Padmore43 emphasized that mis-
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 conduct must be distinguished from academic defi-
ciency. By definition, misconduct is behavior that is wrong
and that one knows (or should know) is wrong and there-
fore will not be cured by remediation. Treating miscon-
duct as academic deficiency could be legally precarious by
holding residents to different legal and performance stan-
dards than other institutional employees.43 Misconduct in-
cludes such fatal flaws as dishonesty, inappropriate touch-
ing, patient abandonment, criminal activity, and covering
up mistakes, thereby putting patients at risk. All incidents
should be investigated and a report generated that consid-
ers extenuating circumstances, if present. In assessing the
culpability of an individual accused of such misconduct,
Hickson et al5,27 recommended using the Reason44 criteria
and asking whether the team member intended to cause
harm, came to work impaired, and knowingly and unrea-
sonably increased risk and whether another team member
in the same situation would act in a similar manner. In cer-
tain situations, recommending a multidisciplinary evalu-
ation can be helpful in elucidating contributing factors and
remediation potential. Final decisions about the resident
are made by the PD, regardless of the majority opinion or
the unpopularity of the decision. The resident may re-
quest a review and only one level of review is necessary.
The Americans With Disabilities Act45 mandates that
educators must make reasonable accommodation to en-
sure that a resident with a disability can complete the cur-
riculum; however, the resident must ask for accommoda-
tion before a performance deficiency occurs. Performance
problems should be addressed as a performance or a be-
havior problem and not as a health issue. For example,
stress must be discussed as it relates to poor performance—
not mental health. In addition, the Americans With Dis-
abilities Act limits when a psychiatric evaluation can be re-
quired and is usually restricted to decisions about fitness
to practice. A physician-patient relationship does not, and
should not, exist between a resident and PD; therefore, if
there is a fitness to practice concern necessitating a refer-
ral to employee health, this must remain confidential and
separate from the academic file. After such evaluations, the
PD should receive notification that appropriate follow-up
is occurring but should not receive medical details. Fu-
ture employers should not be told about impairment ex-
cept to the extent that it involved misconduct (or lack of
fitness for practice) that resulted in employment action.
There is a distinction between the ACGME require-
ments for documentation and what could be considered
acceptable in a court of law (Table 1). Verbal feedback
to the resident is legally acceptable but, although “no
documentation may be enough, more is always bet-
ter.”46(p642) If faculty members are unwilling to put a con-
cern in writing, it can be noted by the recipient of the
complaint or through the competency committee meet-
ing minutes. Legally, evaluations of performance will be
protected if they are good faith exercises of professional
judgment without malicious intent.
CONCLUSIONS
Factors known to put individuals at risk for behavioral prob-
lems should be considered when ranking applicants. It is
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essential to set clear expectations for professional behav-
ior with both faculty and residents and to describe prob-
lem behaviors as a deficiency in one or more competen-
cies. Program directors should incorporate an assessment
of trustworthiness and ability to take responsibility for per-
sonal behavior into resident evaluations and note system
problems that enable unprofessional behavior by provid-
ing secondary gain for such activities. Any complaint or
critical incident, particularly in a new resident, should be
investigated and addressed promptly. Once a problem has
been identified, the resident must be provided with a no-
tice of deficiency and an opportunity to improve, with con-
sequences for failing to address the deficiency. In addi-
tion to participation in a remedial program, the opportunity
for feedback and reflection and postintervention assess-
ment are necessary to determine next steps. While the re-
sponsibility for improvement rests with the resident, the
resident will need guidance in locating appropriate re-
sources. Whatever final decision is made about the resi-
dent, as long as the process is fair and reasonable, that is,
the decision was not arbitrary or capricious, it will be up-
held in court. Legally, verbal concerns are as useful as writ-
ten concerns, and these can be documented by the PD if
the complainant is unwilling to do so. Finally, legal pro-
ceedings and grievance hearings are costly and time-
consuming, so prevention is better than a cure. There-
fore, the importance of intervening early is emphasized.
In conclusion, we have made a number of recommen-
dations for ensuring professional accountability in sur-
gical trainees. The next step will be to conduct a series
of workshops with PDs to promote a uniform evidence-
based approach at a national level to the PRs.
Accepted for Publication: March 13, 2012.
Author Affiliations: Departments of Surgery (Drs San-
fey, Mellinger, R. G. Williams, and Dunnington, and Mss
Boehler and Schwind) and Medical Education (Drs Kla-
men and Roberts), Southern Illinois University School
of Medicine, Springfield; Department of Surgery, North-
western University Feinberg School of Medicine, Chi-
cago, Illinois (Dr DaRosa); Center for Patient and Pro-
fessional Advocacy, Vanderbilt University Medical Center,
Nashville, Tennessee (Dr Hickson); Department of Be-
havioral Sciences, Rush University Medical Center, Chi-
cago, Illinois (Dr B. Williams); Department of Surgery,
Duke University School of Medicine, Durham, North
Carolina (Dr Sudan); Department of Surgery, Washing-
ton University School of Medicine, St Louis, Missouri (Dr
Klingensmith); Department of Surgery, University of Ver-
mont, Burlington (Dr Hebert); MedStar Health, Inc, Ar-
lington, Virginia (Ms Richard); and Division of Educa-
tion, American College of Surgeons, Chicago, Illinois (Dr
Sachdeva).
Correspondence: Hilary Sanfey, MB, BCh, MHPE, De-
partment of Surgery, Southern Illinois University School
of Medicine, Room D308, PO Box 19638, Springfield, IL
62794 (hsanfey@siumed.edu).
Author Contributions: Dr Sanfey had full access to all
the data in the study and takes responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Study concept and design: Sanfey, DaRosa, Klingensmith,
Hebert, Richard, Roberts, Schwind, R. G. Williams,
WWW.ARCHSURG.COM
 Sachdeva, and Dunnington. Acquisition of data: Sanfey,
B. Williams, Boehler, Klamen, Mellinger, Hebert, Schwind,
R. G. Williams, and Sachdeva. Analysis and interpreta-
tion of data: Sanfey, Hickson, B. Williams, Sudan, Mel-
linger, Hebert, R. G. Williams, Sachdeva, and Dunning-
ton. Drafting of the manuscript: Sanfey, DaRosa, and Hebert.
Critical revision of the manuscript for important intellec-
tual content: Sanfey, DaRosa, Hickson, B. Williams, Su-
dan, Boehler, Klingensmith, Klamen, Mellinger, Hebert,
Richard, Roberts, Schwind, R. G. Williams, Sachdeva, and
Dunnington. Statistical analysis: B. Williams. Adminis-
trative, technical, and material support: Sanfey, DaRosa,
Boehler, Hebert, Richard, Schwind, and Sachdeva. Study
supervision: Sanfey, Klamen, Hebert, Richard, and Dun-
nington.
Financial Disclosure: None reported.
Additional Contributions: We acknowledge individu-
als who attended the meeting in Chicago and contrib-
uted to our discussion. The following were from the
American College of Surgeons: Patrice Gabler Blair, MPH,
Associate Director, Division of Education, and Kim Echert,
BA, C-TAGME, Senior Manager, Programs to Enhance
Resident and Medical Student Education. The following
residents participated: Brian George, MD, Department of
Surgery, Massachusetts General Hospital, Surgical Edu-
cation Fellow, Northwestern University Feinberg School
of Medicine; and Amanda Hayman, MD, and Melissa
Pilewskie, MD, Department of Surgery, Northwestern Uni-
versity Feinberg School of Medicine.
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