An assessment of emotional intelligence in emergency medicine resident physicians

Objectives To define the emotional intelligence (EI) profile of emergency medicine (EM) residents, and identify resident EI strengths and weaknesses. Methods First-, second-, and third-year residents (post-graduate years [PGY] 1, 2, and 3, respectively) of Thomas Jefferson University Hospital’s EM Program completed the Emotional Quotient Inventory (EQ-i 2.0), a validated instrument offered by Multi-Health Systems. Reported scores included total mean EI, 5 composite scores, and 15 subscales of EI. Scores are reported as means with 95% CIs. The unpaired, two-sample t-test was used to evaluate differences in means. Results Thirty-five residents completed the assessment (response rate 97.2%). Scores were normed to the general population (mean 100, SD 15). Total mean EI for the cohort was 103 (95%CI,100-108). EI was higher in female (107) than male (101) residents. PGY-2s demonstrated the lowest mean EI (95) versus PGY-1s (104) and PGY-3s (110). The difference in PGY-3 EI (110; 95%CI,103-116) and PGY-1 EI (95, 95%CI,87-104) was statistically significant (unpaired t-test, p<0.01). Highest composite scores were in interpersonal skills (107; 95%CI,100-108) and stress management (105; 95%CI,101-109). Subscale cohort strengths included self-actualization (107); empathy (107); interpersonal relationships (106); impulse control (106); and stress tolerance (106). Lowest subscale score was in assertiveness (98). Self-regard (89), assertiveness (88), and independence (90) were areas in which PGY-2s attained relatively lower scores (unpaired t-test, p<0.05) compared to their peers and the general population. PGY-3’s scored highest in nearly all subscales. Conclusions The EQ-i offers insight into training that may assist in developing EM residents, specifically in self-regard, assertiveness, and self-expression. Further study is required to ascertain if patterns in level of training are idiosyncratic or relate to the natural maturation of residents.


Introduction
Emotional Intelligence (EI) has been broadly defined as one's ability to identify and manage his or her emotions and those of others. 1 First recognized for its value in the business arena, EI has recently been applied to clinical medicine given its ties with academic and professional leadership, enhanced job performance, stress management, and emotional well-being. 2 EI has been a cited key determinant promoting resilience among health professionals against burnout. 3,4 Physicians who are better at expressing emotions had patients rate them as more caring, sensitive, and better at listening. 5 Similarly and importantly in the era of physician metrics, patient satisfaction is strongly correlated to emotionally expressive nonverbal behaviors. [4][5][6] Physicians are often faced with the challenge of perceiving and responding to their own emotions, as well as those of their patients and multidisciplinary teammates. Further understanding the internal thoughts and interlacing emotions a provider experiences is warranted, as it has the potential to improve patient care through enhanced communication and professionalism. 1 The practice of emergency medicine is rooted in teambased health delivery. EM physician responsibilities include, but are not limited to, effectively communicating and properly empathizing with patients, families and their care teams; coordinating care with other providers; and expeditious, holistic decision making. Considering the degree to which EM physicians are expected to rapidly make highstakes decisions, foster interpersonal relationships, and effectively manage stress in the clinical learning environment of the emergency department (ED), the role EI plays in EM physician success cannot be taken lightly.
Front-line physicians who work in the ED and other acute care settings are at the top the list on physician burnout rates. 1 Physician suicide continues to be a major challenge for the medical profession, and residents are not spared from this tragedy. EI has been shown to be essential to successfully cope with stress, as well as to create the foundation of sound mental and physical health. [7][8][9] Therefore, the intersection of EI, mental health, and coping abilities underscores the timeliness and importance of better understanding resident EI to promote and inform educational wellness interventions.
No prior studies to date have assessed emotional intelligence exclusively in EM residents, specifically discrepancies in EI across years in training. Recent studies have included investigations of EI in residents of obstetrics and gynecology (OBGYN), orthopedics, otolaryngology, pathology, pediatrics, and general surgery residency programs. 1,[10][11][12][13] If trends in EM resident trainees do exist, potential training interventions may be appropriately designed to support wellness and address EI. The authors sought to reveal findings that would potentially direct future residency training, curriculum development, and educational programming to prospectively address physician self-awareness and efficacy. If done successfully, such training interventions have the potential to improve wellness, provider-patient communication and, ultimately, health outcomes. The authors hypothesized that there are distinct EI competencies with which EM residents may already have mastery of, specifically in stress tolerance, flexibility, impulse control, interpersonal relationships, and empathy, as these are skills that are inherently part of traditional emergency medicine training. The authors also hypothesized that there may be statistically significant increases in composite EI with progressive advancement through residency training. Findings would be applied to inform future curricular development, optimize existing training programs, and create effective wellness interventions for trainees.

Study design and participants
This cross-sectional study was conducted at an urban EM residency training program. Study recruitment included all EM residents (i.e., post-graduate years [PGY] 1-3) at Thomas Jefferson University (TJU) Hospital in Philadelphia, Pennsylvania. There were no exclusion criteria for participation in this study. The Department of Emergency Medicine at TJU Hospital sponsors a three-year residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME). There are thirty-six residents enrolled in the program.
EI was measured using a single electronic instrument, the EQ-i 2.0 (described below). Unique log-in accounts to access the instrument via a commercial website were sent to all participants' secure, Institutionally-sponsored e-mail addresses. Residents also completed an electronic consent form, followed by a demographic questionnaire that included their self-reported gender and level of residency training. Surveys were sent to residents in the month of February, which coincides with the middle of the residency academic year.
The study was reviewed by the Institutional Review Board (IRB) of the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, Pennsylvania. After IRB review, the study was deemed compliant with all ethical requirements, and was granted approval by the Board. All participants who completed the assessment did so anonymously; no identifying information was collected. The study did not involve animal or human tissue.

Study instrument
The EQ-i 2.0 is a psychometrically validated EI assessment tool derived from Bar-On's (1997) conceptual model of emotional intelligence (Multi-Health Systems, 2011). 14 The EQ-i 2.0 self-assessment is 133 items in length and takes approximately twenty minutes to complete. A participant is asked to read and respond to 133 statements by indicating his/her level of agreement using a 5-point Likert Scale (i.e., 1=never/rarely, 2=occasionally; 3=sometimes; 4=often; 5=always/almost always). 15 The EQ-i 2.0 uses a normative sample of adults, which includes 4,000 self-report ratings from adults residing in the United States (90% of the sample) and Canada (10% of the sample). The EQ-i is based on data gathered from all 50 U.S. states and the District of Columbia, as well as from all ten Canadian provinces. The normative sample matches Census means and is highly representative of the North American general population. 15 EQ-i scores are accompanied by respective computed 95% confidence intervals, and built-in correction factors to counter response bias. 15,16 The EQ-i 2.0 was chosen for both its validity and reliability. Content validity analyses, exploratory factor analyses, and confirmatory factor analyses suggest that the EQ-i 2.0 is a valid measure of EI. Its validity scales (positive impression, negative impression, and inconsistency index) were also validated through expected differences in scores between known invalid responses and those of control groups. [15][16] The EQ-i has sound reliability given its high Cronbach and testretest values. Its Cronbach's α-value of 0.97 gives this assessment tool a high degree of internal consistency. 16 Test-retest correlations are also high for EQ-i 2.0 scores at 2-to-4 weeks (r = 0.92) and at 8 weeks (r = 0.81). 16

Statistical analyses
Descriptive statistics are used to analyze data. Continuous variables are reported as means with standard deviations. Results were normed to the general North American population, in which a mean EI score is 100 with a standard deviation (SD) of 15. Scores are plotted along a normal distribution, with an average score of 100, an upper limit of 145, and SD of 15. The unpaired, two-sample t-test was used to evaluate differences in means.
Total EI scores for emergency medicine residents were computed by MHS software. Five categorical EI composite scores were calculated, including Self-Perception, Self-Expression, Interpersonal Skills, Decision Making, and Stress Management Composites. Furthermore, 15 subscales of emotional intelligence were generated; these include the following: Self-Regard, Self-Actualization, Emotional Self-Awareness, Emotional Expression, Assertiveness, Independence, Interpersonal Relationships, Empathy, Social Responsibility, Problem Solving, Reality Testing, Impulse Control, Flexibility, Stress Tolerance, and Optimism.
Differences in EI amongst groups varying by gender and PGY-training level were assessed. The t-test was utilized to compare means, with significance defined when p < 0.05. This study was fully reviewed and received exemption status by the Institutional Review Board (IRB) of the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, Pennsylvania.

Results
Thirty-five EM residents completed the EQ-i 2.0 from a total of 36 eligible residents for a response rate of 97.2%. Total mean EI for resident trainees was 103.3 (95% CI, 99.8-107.7). Table 1 provides a summary of mean EI scores for residents by gender and post-graduate year. Collectively, mean EI were higher in female residents (106; 95% CI, 100-112) than male residents (101; 95% CI, 95-108); the difference in means by gender was not statistically significant.

Discussion
In this study, patterns of emotional intelligence in EM residents are examined across gender and post-graduate year of training. To this effect, a working EI profile of EM residents at our institution is defined, and trends across our three progressive classes of residents are described. Residents scored above the general population in total EI and across four of the five composite scales. A positive linear relationship between years of training and EI was not observed in the sample. In fact, the mean PGY-2 EI score was not only lower than the mean PGY-1 score but also below the national average. This difference in total EI between PGY-2s and the general population was not statistically significant. A statistical significant difference in total EI score, however, was observed between PGY-2 and PGY-3 cohorts, raising the question as to what are the factors that contributed to this finding.
Two potential possibilities merit consideration: either the PGY-2 cohort was an outlier, with poor baseline EI; or being in the middle of their training, when stress and self-doubt are at their highest, was responsible for their underperformance. The second-year EM resident is expected to evaluate a larger volume of patients; to have acquired a higher level of medical knowledge, and to care for critically-ill patients with a marked increase in responsibility. 17 The literature suggests that caring for severely-and critically-ill patients can have a negative toll on a provider's emotional and physical well-being, especially in the nascent stages of transition. [18][19][20] Further investigation with longitudinal reassessment of trainee EI may be helpful in clarifying this observation. If so, additional wellness interventions may be required at this potential training nadir.
Based on overall findings, the data suggests that residents may be struggling with self-expression and self-perception. This is perhaps not surprising when one considers the overall milieu of healthcare-based education, which has been criticized for poor adoption of the medical humanities, 21 a meagre emphasis on self-expression, 22 and questionable self-reflective exercises. 23 Training environments across residencies are quite variable, and often dependent on the supervising faculty to create a culture that encourages reflection and feedback. While some supervising faculty physicians may nurture environments that support discussion and debate, others may opt for a different, less supportive style. 24 Lastly, it is plausible that residents may struggle with their large and varied time commitments. Self-expression is difficult to practice when balanced against the clinical, academic, and professional demands a trainee requires to advance.
As stewards of physicians-in-training, residency leadership have the opportunity to create training opportunities to assist the resiliency needed to cope with these challenges. Two particular areas of interest that can potentially address the aforementioned include learner well-being and resident self-expression.
Training interventions that promote resident wellness are paramount, 24 and can benefit from an improved understanding of cohort EI strengths and weakness. One the most studied interventions on resident wellness, thus far, has been the introduction of work hour restrictions for residents, with many studies revealing a positive impact on self-perceived resident wellness, fatigue, burnout, and physiological distress. [25][26][27] Stanford University provides another exemplar, their Balance in Life Program, which provides their residents with mentorship and leadership training; stocks resident environments with healthy foods and snacks; offers residents resources that foster mental, emotional and physical health; and hosts social gatherings and events. 28 Medical education programs that encourage self-expression exist and typically approach learners through various artistic activities such as self-reflective exercises. [29][30][31][32] They have shown modest improvements in medical student EM clerkship performance. 32 The fact that second-year residents exhibited lower scores relative to the general population in self-regard and assertiveness, as well as lower scores in stress tolerance and optimism relative to their counterparts, is of high concern. Transitions in residency training, graded responsibility, and increased workloads are tipping points in residency, and require sound emotional intelligence to counteract them. Attention to trainee stress tolerance, assertiveness, and optimism is key to promoting a culture of wellness and resiliency during post-graduate training. In addition to the aforementioned, promoting an open culture of learning and discussion in the emergency department, strengthening resident education, and encouraging real-time feedback for residents can further promote resident wellness.
Integrating newer learning modalities, such as simulation-based education, 33 mixed modality/asynchronous learning, [34][35][36] and the free-open-access-medical education (FOAMED) electronic movement 36 can also foster the intellectual exchange of ideas and socialize the learning experience. 35 Additionally, placing an emphasis on continuous, high-quality feedback in the ED can potentially promote EI through better and more accurate reflection. 36 That PGY-3s demonstrated the highest EI scores is encouraging. While correlation is not causation, this potentially suggests that EM residency training may have a positive impact on the development of emotional intelligence.
While intuitive, other specialties have demonstrated the opposite pattern. 11 Given the marked difference comparing surgical subspecialty training to EM, it's unclear if the contradictory results are related to practice variation or represent a true dispute. This contradiction merits further study employing qualitative approaches (i.e., resident interviews, focus group) and perhaps aptitude-based assessments of emotional intelligence.

Limitations
Although our study is one of the first to measure EI in EM residents, it has a number of limitations. Despite a >97% response rate, our total cohort size was 35 residents or 11-12 per post-graduate training year. A larger sampling of participants would have provided for more robust data and trends of emotional intelligence across years of training. Furthermore, our study takes a 'point-in-time' view of EI with no assessment of how EI trends for an individual over time. Subsequent studies of emotional intelligence should re-test participants at the beginning and start of each year of residency training; in this manner, each participant would also serve as a control for himself/herself. Similarly, the data was not segregated by age.
The science of assessing EI remains a challenge, and despite being a psychometrically validated tool, the EQ-i 2.0 has its own intrinsic limitations. The EQ-i 2.0 relies on a participant's self-assessment. While the instrument incorporates correction factors for item responses, it is conceivable that participants may opt to deliberately overestimate and/or underestimate their responses to statements in hopes of improving their EI scores. While this would be difficult to account for with the EQ-i 2.0, other instruments of emotional intelligence are aptitude-and task-based, making deliberate over-and underestimations more challenging. The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT), as an example, is an ability-based measure of emotional intelligence, and tests the participant's ability to perceive, use, understand, and regulate his/her emotions. 38 Future studies of emotional intelligence utilizing several different assessments and correlating results may offer a more accurate representation of EI, and change in EI, over the course of training.
Finally, the current study does not correlate EI with resident performance during training. It would be of value to ascertain if EI has the ability to predict resident performance (i.e., does a low subscale score in empathy correlate with poor patient satisfaction ratings). Similarly, future studies should also aim to collect data on residents' perceived stress level. If a correlation between EI and perceived stress level does exist, it is quite possible that EI assessments have the potential to identify vulnerable and at-risk resident physicians who may require immediate and targeted wellness interventions.

Conclusions
The present study identifies EI strengths and weaknesses in a cohort of EM residents, which has the potential to inform education leadership in efforts to improve wellness and training. A linear relationship of emotional intelligence with EM residency training was not identified in the current study; however, data suggests that there are specific aspects of EI that decline in the second year of training. While a qualitative evaluation is needed to identify the underlying themes that would explain these observations, residency and wellness training interventions should address learner self-regard, assertiveness, stress tolerance, and self-expression. Findings of this study offer significant insights into effective medical education programming in EM, specifically for program design for EM resident trainees, particularly during a climate of heightened awareness of resident burnout, mental health, resiliency, and wellness. The overarching goal will be to align training in EI with core competencies and milestones set forward by the Accreditation Council for Graduate Medical Education. Further research will be needed to clarify the natural course of EI development in resident learners and its impact on success during training.