Assessing the Culture of Residency Using the C - Change Resident Survey: Validity Evidence in 34 U.S. Residency Programs
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A practical instrument is needed to reliably measure the clinical learning environment and professionalism for residents.
To develop and present evidence of validity of an instrument to assess the culture of residency programs and the clinical learning environment.
During 2014–2015, we surveyed residents using the C - Change Resident Survey to assess residents’ perceptions of the culture in their programs.
Residents in all years of training in 34 programs in internal medicine, pediatrics, and general surgery in 14 geographically diverse public and private academic health systems.
The C - Change Resident Survey assessed residents’ perceptions of 13 dimensions of the culture: Vitality, Self-Efficacy, Institutional Support, Relationships/Inclusion, Values Alignment, Ethical/Moral Distress, Respect, Mentoring, Work–Life Integration, Gender Equity, Racial/Ethnic Minority Equity, and self-assessed Competencies. We measured the internal reliability of each of the 13 dimensions and evaluated response process, content validity, and construct-related evidence validity by assessing relationships predicted by our conceptual model and prior research. We also assessed whether the measurements were sensitive to differences in specialty and across institutions.
A total of 1708 residents completed the survey [internal medicine: n = 956, pediatrics: n = 411, general surgery: n = 311 (51% women; 16% underrepresented in medicine minority)], with a response rate of 70% (range across programs, 51–87%). Internal consistency of each dimension was high (Cronbach α: 0.73–0.90). The instrument was able to detect significant differences in the learning environment across programs and sites. Evidence of validity was supported by a good response process and the demonstration of several relationships predicted by our conceptual model.
The C - Change Resident Survey assesses the clinical learning environment for residents, and we encourage further study of validity in different contexts. Results could be used to facilitate and monitor improvements in the clinical learning environment and resident well-being.
KEY WORDSresidents culture of medicine clinical learning environment quantitative survey resident well-being
The authors gratefully acknowledge the funding support of the Arnold P. Gold Foundation and supplemental funds from the Committee of Interns and Residents, the University of New Mexico Health Sciences Center, Boston Medical Center, and Oakland University William Beaumont School of Medicine. We thank Vasilia Vasiliou and Alexander Feldman for their excellent assistance with manuscript preparation. We are grateful to the many hardworking residents who took time to complete the survey.
An early phase of the work was presented orally and as a poster at the 2016 ACGME Annual Educational Conference, February 2016. There has been no prior publication of this work.
Compliance with Ethical Standards
Conflict of Interest
The fact that the survey under discussion is funded at any time by financial support for administering the survey and analyzing data, and that any investigator could be paid from these funds, may seem to qualify in the strictest sense as a potential conflict of interest in a paper reporting on the survey’s validity. In this regard, the National Initiative on Gender, Culture and Leadership in Medicine, C - Change, is entirely externally funded. All grants and contracts from various institutions requesting our survey administration and “blind” data analysis of collected data are awarded to Brandeis University, which pays some salary support to some of the investigators (LP, JC, RB, SS). In this study, all survey work was paid for by a grant from the Arnold P. Gold Foundation and supplemental funders. C - Change maintains rigorous scientific standards for conducting its studies, and there is complete separation of income flowing into the University for the overall Center support and the survey administration and analysis.
IRB approval was obtained from Brandeis University.
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