What Is the Best Way to Assess Professionalism in Resident Trainees?

Professionalism in medicine encompasses the values and behaviors that establish trust between physicians, patients, and society. It includes prioritizing patient welfare, adhering to ethical principles, and maintaining a standard of clinical excellence. Despite its importance, professionalism is difficult to assess with the widespread use of instruments lacking strong validity evidence, combined with variable standards across specialties and programs. Over the past two decades, professionalism in medicine has moved away from broad theoretical ideals toward specific observable behaviors as medical training has shifted toward competency-based medical education. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) has established professionalism as one of six core competencies for residents in its Milestones framework that has been used for program accreditation since 2013. Professionalism is particularly important for surgical trainees, as surgical care occurs in high-risk, team-based environments where unprofessional behaviors can have serious consequences. However, what individual groups value as the most important aspects of professionalism can vary depending on their context. Various surgical specialties have created/adapted instruments to assess professionalism in trainees, but it is uncertain if these tools can accurately capture and longitudinally track behaviors. Understanding the methods available to assess professionalism for trainees is essential as residency is a critical period for identifying, reinforcing, and remediating behavior. Moreover, studies have shown that low assessments of professionalism in training are related to future board disciplinary actions, as well as poor ratings of patient experience in early unsupervised practice. In this review, we describe the current state-of-the-art options for evaluating professionalism in surgical trainees. A literature review was conducted in PubMed, Embase, and Scopus, using keywords and MeSH terms related to professionalism (Data S1). A total of 1071 unique records were screened using Covidence by title and abstract, and 123 studies underwent full-text review. From these, four studies were selected, and a fifth study by Sundt et al. was selected from a manual review of references. The first study by Santen et al. examined the ACGME's professionalism Milestones, which were standardized across specialties between 2019 and 2022 [1]. The professionalism Milestones assess four subcompetencies: professional behavior, ethical principles, accountability/conscientiousness, and knowledge of factors of well-being. Analyzing Milestone ratings for over 57,000 PGY-1 residents across six specialties (including surgery), Santen et al. found that variability in Milestone ratings was driven by specialty and by residency programs, with far less variation attributable to individual learners. They also observed that ~12% of residents received the same score across sub-competencies (“straight-lining”), with the highest rates seen in assessments of surgical trainees (38%). These findings highlight the limitations of relying solely on the Milestones to assess professionalism, underscoring the need for more reliable assessment methods and more individualized feedback for trainees. To address some of these limitations, Batra et al. piloted the Mini Clinical Evaluation Exercise (mini-CEX) as a formative assessment tool for surgical residents [2]. The mini-CEX is a workplace-based assessment performed after select clinical encounters that has been widely adopted in nonsurgical fields. Two of its seven questions relate to professionalism: One on humanistic qualities/professionalism and one on counseling skills. Batra et al. collected 80 mini-CEXs for 16 surgical residents, demonstrating its utility for evaluating trainee behavior as well as offering real-time feedback after encounters to promote learning. As a professionalism assessment, however, a major limitation of the mini-CEX is that it asks for only a global assessment of professional behaviors, relying on faculty members to give more detailed narrative feedback, increasing the administrative burden. Recently, other groups have moved toward multisource feedback tools. The American Board of Orthopedic Surgery (ABOS) developed the ABOS Behavioral Tool (ABOSBT)—a 360° assessment tool that examines five observable behavioral domains (ethics, communication, interpersonal skills, reliability, and continuous improvement) and is rated by faculty, peers, and other team members. Armstrong et al. conducted a pilot study at 18 residency programs and analyzed 9892 assessments across 449 residents [3]. They found that while the vast majority of residents scored highly (97.6%), the tool was able to detect 81% (26 of 32) of residents who were previously scored as low performers for professionalism by their program directors at the outset of the study. Since this pilot, the ABOS has instituted the ABOSBT as a requirement for residents who intend to sit for initial board certification, with a minimum of six completed assessments per postgraduate year 2–5. The ABOS’ design and implementation of a multisource and multiyear assessment process using standardized behavioral descriptors reflects a shift toward a more longitudinal, practice-based approach to assessing professionalism in trainees. Similarly, the American Board of Thoracic Surgery will require 360° evaluations through the PULSE 360 Program for candidates for initial certification beginning in 2026 [4]. Residents will be assessed twice: Once in the spring of their penultimate year of training and again in the fall of their final year. PULSE 360 is a multisource feedback platform that replaces a prior yes/no professionalism checkbox used by program directors. It collects Likert-scale ratings and narrative comments from raters (e.g., faculty, coresidents, advanced practitioners, and nurses) to provide a comprehensive review of a resident's professional behaviors. This approach is intended to support the development of individualized, actionable learning plans, although its late implementation in training may limit opportunities for remediation. Internationally, the Royal Australasian College of Surgeons (RACS) has implemented the assessment of professionalism through its competency framework [5]. Drawing upon the Non-Technical Skills for Surgeons (NOTSS) assessment, RACS incorporates professionalism as one of nine primarily nontechnical skill domains. Each domain includes three behavior descriptions with four positive and four negative ratings. Dickinson et al. reviewed the methods for assessing RACS competencies, emphasizing the use of multisource feedback such as patient surveys to evaluate professionalism and other nontechnical domains [5]. Furthermore, Dickinson et al. outlined remediation resources, including audit and peer review processes with outlier-management guidelines, peer-support programs, and complaint/incident investigations. This international example highlights a comprehensive approach to assessing and remediating professionalism among other nontechnical abilities in training. In summary, assessing professionalism in surgical trainees is critical for competency-based graduate medical education. While otolaryngology–head and neck surgery programs in the United States continue to rely primarily on the ACGME Milestones to assess professionalism, emerging work within other surgical fields highlights the limitations of existing instruments and the need for more detailed, longitudinal approaches. Contemporary methods, including workplace-based and multisource assessments, reflect a shift toward evaluating professionalism as a set of dynamic, observable behaviors that are time and place dependent. Effective assessment of professionalism in surgical trainees should integrate multimodal, behaviorally anchored tools with multisource feedback from faculty, staff, and other team members, applied longitudinally across training to capture professionalism as an evolving competency that can change throughout the lifecycle of training. N/A. This work was supported by funding from the American Board of Medical Specialties Research and Education Foundation (REF grant 2025-26). The authors declare no conflicts of interest. The authors have nothing to report. Data S1: Search terms for literature review. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.