Resident Self-Assessment and Self-Reflection: University of Wisconsin-Madison’s Five-Year Study

  • Christopher Hildebrand
  • Elizabeth Trowbridge
  • Mary A. Roach
  • Anne Gravel Sullivan
  • Aimee Teo Broman
  • Bennett VogelmanEmail author
Original Article



Chart review represents a critical cornerstone for practice-based learning and improvement in our internal medicine residency program.


To document residents’ performance monitoring and improvement skills in their continuity clinics, their satisfaction with practice-based learning and improvement, and their ability to self-reflect on their performance.


Retrospective longitudinal design with repeated measures.


Eighty Internal Medicine residents abstracted data for 3 consecutive years from the medical records of their 4,390 patients in the University of Wisconsin-Madison (UW) Hospital and Clinics and William S. Middleton Veterans Administration (VA) outpatient clinics.


Logistic modeling was used to determine the effect of postgraduate year, resident sex, graduation cohort, and clinic setting on residents’ “compliance rate” on 17 nationally recognized health screening and chronic disease management parameters from 2003 to 2007.


Residents’ adherence to national preventive and chronic disease standards increased significantly from intern to subsequent years for administering immunizations, screening for diabetes, cholesterol, cancer, and behavioral risks, and for management of diabetes. Of the residents, 92% found the chart review exercise beneficial, with 63% reporting gains in understanding about their medical practices, 26% reflecting on specific gaps in their practices, and 8% taking critical action to improve their patient outcomes.


This paper provides support for the feasibility and practicality of this limited-cost method of chart review. It also directs our residency program’s attention in the continuity clinic to a key area important to internal medicine training programs by highlighting the potential benefit of enhancing residents’ self-reflection skills.


practice-based learning and improvement graduate medical education chart review ambulatory care settings 



Completion of this paper was made possible by a grant from the Medical Education and Research Committee (MERC) of the University of Wisconsin-Madison School of Medicine and Public Health as well as by the support of the Education Innovation Project of the Residency Review Committee for Internal Medicine, of which we are a participating residency. This research was also supported by the University of Wisconsin Institute for Clinical and Translational Research, funded through an NIH Clinical and Translational Science Award (CTSA), grant no. 1 UL1 RR025011. Earlier results of this paper were presented at the Association of Program Directors in Internal Medicine meeting (2004). We wish to acknowledge the programmatic efforts of Suzy Griffiths, Toni Prisk, Vonnie Schoenleber, Jessalyn Richter, and Erik Stava at various stages in the process of this work.

Conflict of Interest

None disclosed.


  1. 1.
    Swing SR. The ACGME outcome project: Retrospective and prospective. Med Teach. 2007;29(7):648–54.PubMedCrossRefGoogle Scholar
  2. 2.
    Duffy FD, Lynn LA, Didura H, et al. Self-assessment of practice performance: development of the ABIM Practice Improvement Module (PIM). J Contin Educ Health Prof. 2008;28(1):38–46, Winter.PubMedCrossRefGoogle Scholar
  3. 3.
    Houston TK, Wall T, Allison JJ, et al. Implementing achievable benchmarks in preventive health: a controlled trial in residency education. Acad Med. 2006;81(7):608–16, Jul.PubMedCrossRefGoogle Scholar
  4. 4.
    Foy R, Eccles MP, Jamtvedt G, Young J, Grimshaw JM, Baker R. What do we know about how to do audit and feedback? Pitfalls in applying evidence from a systematic review. BMC Health Serv Res. 2005;13;5:50, Jul.Google Scholar
  5. 5.
    Kogan JR, Reynolds EE, Shea JA. Effectiveness of report cards based on chart audits of residents’ adherence to practice guidelines on practice performance: a randomized controlled trial. Teach Learn Med. 2003;15(1):25–30, Winter.PubMedCrossRefGoogle Scholar
  6. 6.
    Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care. 2006;15(6):433–6, Dec.PubMedCrossRefGoogle Scholar
  7. 7.
    Haan CK, Edwards FH, Poole B, Godley M, Genuardi FJ, Zenni EA. A model to begin to use clinical outcomes in medical education. Acad Med. 2008;83(6):574–80, Jun.PubMedCrossRefGoogle Scholar
  8. 8.
    Lyman JA, Schorling J, Nadkarni M, May N, Scully K, Voss J. Development of a web-based resident profiling tool to support training in practice-based learning and improvement. J Gen Intern Med. 2008;23(4):485–8, Apr.PubMedCrossRefGoogle Scholar
  9. 9.
    Keirns CC, Bosk CL. The unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. 2008;83(5):498–502, May.PubMedCrossRefGoogle Scholar
  10. 10.
    Mladenovic J, Shea JA, Duffy FD, Lynn LA, Holmboe ES, Lipner RS. Variation in internal medicine residency clinic practices: assessing practice environments and quality of care. J Gen Intern Med. 2008;23(7):914–20, Jul.PubMedCrossRefGoogle Scholar
  11. 11.
    Stevens DP, Sixta CS, Wagner E, Bowen JL. The evidence is at hand for improving care in settings where residents train. J Gen Intern Med. 2008;23(7):1116–7, Jul.PubMedCrossRefGoogle Scholar
  12. 12.
    Sisson SD, Boonyasai R, Baker-Genaw K, Silverstein J. Continuity clinic satisfaction and valuation in residency training. J Gen Intern Med. 2007;22(12):1704–10, Dec.PubMedCrossRefGoogle Scholar
  13. 13.
    Cook DA, Beckman TJ, Thomas KG, Thompson WG. Adapting web-based instruction to residents’ knowledge improves learning efficiency: a randomized controlled trial. J Gen Intern Med. 2008;23(7):985–90, Jul.PubMedCrossRefGoogle Scholar
  14. 14.
    Dearinger AT, Wilson JF, Griffith CH, Scutchfield FD. The effect of physician continuity on diabetic outcomes in a resident continuity clinic. J Gen Intern Med. 2008;23(7):937–41, Jul.PubMedCrossRefGoogle Scholar
  15. 15.
    Warm EJ, Schauer DP, Diers T, et al. The ambulatory long-block: an accreditation council for graduate medical education (ACGME) educational innovations project (EIP). J Gen Intern Med. 2008;23(7):921–6, Jul.PubMedCrossRefGoogle Scholar
  16. 16.
    Lynch DC, Swing SR, Horowitz SD, Holt K, Messer JV. Assessing practice-based learning and improvement. Teach Learn Med. 2004;16(1):85–92, Winter.PubMedCrossRefGoogle Scholar
  17. 17.
    Morrison LJ, Headrick LA. Teaching residents about practice-based learning and improvement. Jt Comm J Qual Patient Saf. 2008;34(8):453–9, Aug.PubMedGoogle Scholar
  18. 18.
    Moskowitz EJ, Nash DB. Accreditation Council for Graduate Medical Education competencies: practice-based learning and systems-based practice. Am J Med Qual. 2007;22(5):351–82, Sep–Oct.PubMedCrossRefGoogle Scholar
  19. 19.
    Oyler J, Vinci L, Arora V, Johnson J. Teaching internal medicine residents quality improvement techniques using the ABIM’s practice improvement modules. J Gen Intern Med. 2008;23(7):927–30, Jul.PubMedCrossRefGoogle Scholar
  20. 20.
    Halverson LW, Sontheimer D, Duvall S. A residency clinic chronic condition management quality improvement project. Fam Med. 2007;39(2):103–11, Feb.PubMedGoogle Scholar
  21. 21.
    Thomas KG, Thomas MR, Stroebel RJ, et al. Use of a registry-generated audit, feedback, and patient reminder intervention in an internal medicine resident clinic- A randomized trial. J Gen Intern Med. 2007;22(12):1740–4, Dec.PubMedCrossRefGoogle Scholar
  22. 22.
    Holmboe ES, Prince L, Green M. Teaching and improving quality of care in a primary care internal medicine residency clinic. Acad Med. 2005;80(6):571–7, Jun.PubMedCrossRefGoogle Scholar
  23. 23.
    U.S. Preventative Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140(7):554–6, Apr 6.Google Scholar
  24. 24.
    National Committee for Quality Assurance <>. Accessed 2008 February 26.
  25. 25.
    Mezirow J. Transformative dimensions of adult learning. San Francisco: Jossey-Bass; 1991.Google Scholar
  26. 26.
    Zeger SL, Liang KY, Albert PS. Models for longitudinal data: a generalized estimating equation approach. Biometrics. 1988;44(4):1049–60, Dec.PubMedCrossRefGoogle Scholar
  27. 27.
    Statistical Analysis Software Package Version 9.1. Cary, NC: SAS Institute Inc.Google Scholar
  28. 28.
    Meyers FJ, Weinberger SE, Fitzgibbons JP, Glassroth J, Duffy FD, Clayton CP. Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Acad Med. 2007;82(12):1211–9, Dec.PubMedCrossRefGoogle Scholar
  29. 29.
    Kern DE, Harris WL, Boekeloo BO, Barker LR, Hogeland P. Use of an outpatient medical record audit to achieve educational objectives: changes in residents’ performances over six years. J Gen Intern Med. 1990;5(3):218–24, May–Jun.PubMedCrossRefGoogle Scholar
  30. 30.
    Holmboe ES, Bowen JL, Green M, et al. Reforming internal medicine residency training. A report from the Society of General Internal Medicine’s task force for residency reform. J Gen Intern Med. 2005;20(12):1165–72, Dec.PubMedCrossRefGoogle Scholar
  31. 31.
    Willett LL, Palonen K, Allison JJ, et al. Differences in preventive health quality by residency year. Is seniority better. J Gen Intern Med. 2005;20(9):825–9, Sep.PubMedCrossRefGoogle Scholar
  32. 32.
    Kiefe CI, Allison JJ, Williams OD, Person SD, Weaver MT, Weissman NW. Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial. JAMA. 2001;285(22):2871–9, Jun 13.PubMedCrossRefGoogle Scholar
  33. 33.
    Duffy FD, Holmboe ES. Self-assessment in lifelong learning and improving performance in practice: physician know thyself. JAMA. 2006;296(9):1137–9, Sep 6.PubMedCrossRefGoogle Scholar
  34. 34.
    Bowen JL, Salerno SM, Chamberlain JK, Eckstrom E, Chen HL, Brandenburg S. Changing habits of practice. Transforming internal medicine residency education in ambulatory settings. J Gen Intern Med. 2005;20(12):1181–7, Dec.PubMedCrossRefGoogle Scholar
  35. 35.
    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(9):1094–102.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Christopher Hildebrand
    • 1
  • Elizabeth Trowbridge
    • 2
  • Mary A. Roach
    • 2
  • Anne Gravel Sullivan
    • 2
  • Aimee Teo Broman
    • 2
  • Bennett Vogelman
    • 2
    • 3
    Email author
  1. 1.William S. Middleton Veterans Administration HospitalMadisonUSA
  2. 2.University of Wisconsin-Madison School of Medicine and Public HealthMadisonUSA
  3. 3.Professor and Senior Associate Chair of EducationMadisonUSA

Personalised recommendations