The results expose a pattern of performance associated with unprofessional behavior, and suggest that clinical excellence and unprofessional behavior rarely coexist.

The authors examined residents' clinical performances in five anesthesiology departments in U.S. teaching hospitals. The data were organized by daily use of the Clinical Anesthesia System of Evaluation, which categorizes and quantifies the narrative comments of faculty. The study was designed to identify predictor categories (particular performance characteristics of residents) for the residents' overall performances and their scores in handling critical incidents (those incidents that could or would have caused significant morbidity or mortality had faculty not intervened). More than 9,000 comments made by 163 faculty about 45 residents were analyzed. Residents' noncognitive skills that were predictors of overall performance were Conscientiousness, Management, Confidence, Critical Incidents, and Knowledge. Conscientiousness and Composure predicted two-thirds of the variability in critical incidents' scores. Path analysis verified causal relationships between the hypothesized predictors and critical incidents. For the residents studied, inadequate noncognitive performance in some areas was a powerful (p less than .0005) predictor of overall clinical performance and was related to the occurrence of critical incidents.

We have found that the Clinical Anesthesia System of Evaluation (CASE) method provides information regarding clinical performance of residents and critical incidents that is not available from other sources. As a result, it expands the dimensions of the evaluation process and improves validity. In addition, the technique has helped address the concerns of many investigators. (1) It provides specific, real-time evaluations that permit early intervention, improve feedback and guide remediation; (2) it improves sampling techniques by increasing the breadth and volume of evaluators and settings; (3) it enhances the discriminatory power of the evaluation process; and (4) it improves documentation.

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