Research Report Factors Affecting Resident Performance: Development of a Theoretical Model and a Focused Literature Review Maya Mitchell, MD, Malathi Srinivasan, MD, Daniel C. West, MD, Peter Franks, MD, Craig Keenan, MD, Mark Henderson, MD, and Michael Wilkes, MD, PhD Abstract Purpose The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance. Method Using expert consensus panel, in 2002– 03 the authors developed a hy- pothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), inter- mediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used fac- tors from the model to focus a PubMed search (1967–2002) for all original arti- cles related to the factors of individual resident performance. Results The authors found 52 original studies that examined factors of an individual resident’s performance. They describe each study’s measurement instrument, study design, major findings, and limita- tions. Studies were categorized into five domains: learning styles/personality, so- cial/financial factors, practice prefer- ences, personal health, and response to job environment. Few studies examined intermediate or final performance out- comes. Most were single-institution, cross-sectional, and survey-based studies. Conclusions Attempting to understand resident per- formance without understanding factors that influence performance is analogous to examining patient adherence to medi- cation regimens without understanding the individual patient and his or her envi- ronment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the resident’s actual job performance. Additionally, they identify and discuss major gaps in the educational literature. Acad Med. 2005; 80:376 –389. The clinical performance of physicians has come under increasing scrutiny as greater public attention is paid to the quality of health care. 1 In the past few years, national accreditation and govern- mental agencies have begun using process and quality of care benchmarks (such as community-acquired pneumonia treat- ment and angiotensin-converting enzyme inhibitor usage) as part of accreditation and reimbursement schemas. 2,3 As a re- sult, residency programs, where physi- cians are taught how to practice medi- cine, have also come under closer scrutiny. 4 Medical educators, with guid- ance from the Accreditation Council for Graduate Medical Education (ACGME), 5 are trying to improve the performance of future practicing physicians. However, ba- sic questions still remain unanswered. How do educators and administrators under- stand the key factors affecting physician performance? How do we define and mea- sure physician performance? What effect do the factors of individual physician (e.g., learning style, job stress, medical debt, per- sonality traits) have on performance? Focusing on residents, we attempted to answer these questions by conceptualiz- ing factors affecting an individual physi- cian’s performance, and by conducting a systematic review on a subset of those factors. We developed a theoretical model of individual performance that conceptualizes the interactions among the individual practitioner, the system of care in which he or she practices, and the models of education used to teach resi- dents. Performance has been defined by Webster’s as “the execution of an ac- tion,” 6 We defined an individual physi- cian’s performance as the actions under- taken during the process of patient care. These actions themselves are influenced by an individual physician’s knowledge, skills, attitudes, and habits. If the knowl- edge, skills, attitudes, and habits comport with professional standards, the physician may be observed to be performing com- petently. 7 From the perspective of patient care, a physician who treats congestive heart failure must understand the patho- physiology of cardiomyopathy and avail- able treatment options (knowledge). The physician must use that knowledge to treat the patient and communicate effec- tively (skills), and believe that the patient Dr. Mitchell is chief resident, Department of Medicine, University of California, Davis, School of Medicine, Sacramento, California. Dr. Srinivasan is assistant professor, Department of Medicine, University of California, Davis, School of Medicine, Sacramento, California. Dr. West is associate professor and residency program director, Department of Pediatrics, University of California, Davis, School of Medicine, Sacramento, California. Dr. Franks is professor, Department of Family and Community Medicine, University of California, Davis, School of Medicine, Sacramento, California. Dr. Keenan is assistant professor, Department of Medicine, University of California, Davis, School of Medicine, Sacramento, California. Dr. Henderson is associate professor, Department of Medicine, University of California, Davis, School of Medicine, Sacramento, California. Dr. Wilkes is professor and vice-dean for medical education, University of California, Davis, School of Medicine, Sacramento, California. Correspondence should be addressed to Dr. Srinivasan, Department of Medicine, University of California, Davis, School of Medicine, 4150 V. Street, Suite 2400, Sacramento, CA 95817; telephone: (916) 734-7005; e-mail: malathi@ucdavis.edu. Academic Medicine, Vol. 80, No. 4 / April 2005 376