Forum Theatre to Address Peer-to-Peer Mistreatment in General Surgery Residency.

OBJECTIVE: Mistreatment is widespread in graduate medical education, and much attention has been generated on this topic and its relationship to burnout in general surgery residency. In particular, peer-to-peer mistreatment poses a developmental dilemma - as junior residents find themselves mistreated and some turn around and perpetuate that mistreatment. There is a paucity of effective interventions. Forum Theatre (FT) is a novel educational tool to engage participants in solving difficult situations. We present the use of FT as a tool to explore solutions to address peer-to-peer mistreatment in a surgery residency. FT starts with the performance of a culture-specific conflict scenario and then invites the audience to participate in renditions of the situation ending in a collective solution. DESIGN: Stakeholder support was obtained from the general surgery program leadership. Time was protected during two 1-hour scheduled wellness didactic sessions. First, focus groups with each PG year identified the residents' experience of mistreatment. Themes regarding peer-to peer mistreatment were identified and presented to a group of 3 volunteer actor residents who chose to focus on the unintended consequences of public, corrective feedback with the understanding this would be presented to the residency at large. Following this, they developed a scenario for enactment which was implemented during the second didactic session. The enacted scenario posed a problem with public feedback ending unsatisfactorily. The audience was then invited to engage the actors and participate in replays of the situation until a collective solution was identified. Retrospective pre-post survey and a 6-month post survey were administered. SETTING: General surgery residency at University of Texas Health San Antonio. PARTICIPANTS: General surgery residents. 32 of 66 (48.5%) residents participated. RESULTS: Participants noted an improved understanding of mistreatment, felt more confident in recognizing mistreatment, reported improved confidence in their ability to intervene when witnessing mistreatment and to recognize when they themselves were involved in mistreatment (p < 0.001 for all). In fact, of the residents who reported participating in mistreatment, 100% reported directing it towards peers. After the FT, 89% of residents said they "definitely" or "most likely" recommended participating in a FT to address mistreatment. 85.7% reported that the intervention was moderately to extremely effective for teaching topics in professionalism. These trends remained steady in the survey 6 months after the intervention as well. CONCLUSIONS: We found FT was feasible to implement in a busy general surgery residency and well received with sustained, self- reported behavior change. FT is a novel tool to engage residents to self-evaluate and participate in methods to address mistreatment. FT interventions can be tailored to the local culture to address conflicts specific to that setting.

Lived Experiences of Mistreatment in a General Surgery Residency.

OBJECTIVE: Explore the lived experiences of General Surgery residents to identify how they perceive, define mistreatment, and which factors can contribute to or mitigate mistreatment within the Clinical Learning Environment. DESIGN: This is a phenomenological study conducted during 2019-2020 using Giorgi's psychological descriptive phenomenology methodology. Researcher bias, trustworthiness, and triangulation were addressed using bracketing, check-ins with program leadership, comparisons to resident survey, and team consensus based on Consensual Qualitative Research. SETTING: General Surgery Residency program at Long School of Medicine, UT Health San Antonio, Texas. PARTICIPANTS: All residents in the general surgery program were invited to participate (n= 66, 43% female and 63% non-Hispanic). Specific demographic and identifying data for each participant was not collected. Approximately 50 (76% of program) residents from General Surgery participated. RESULTS: We were able to identify four themes that helped to delineate the lived experience of residents including program cultural factors, resident internal processing, and perceived effects of mistreatment by the residents. The resulting psychological structure and conceptual framework help clarify the interrelations between the themes and the Clinical Learning Environment. The scenarios discussed were adapted and depersonalized to use as prompts for the Forum Theater intervention. This project set out to explore resident's lived experiences and allow the data to reveal the main outcomes. The data was coded and analyzed following strict guidelines from descriptive psychological phenomenology and Consensual Qualitative Research with the aim of informing a later experiential intervention based on Forum Theater. CONCLUSIONS: The lived experience of general surgery residents helped identify cultural factors and behaviors that contribute to and/or mitigate mistreatment providing information to plan interventions at the resident and faculty level. Mitigating or stopping mistreatment can improve the Clinical Learning Environment and hence, the quality of training.

Addressing Peer-to-Peer Resident Mistreatment Through the Use of Forum Theatre: A Pilot Intervention.

PROBLEM: Residents may experience mistreatment by faculty, peers, nurses, or patients. While faculty are reportedly the primary contributors to mistreatment, residents can also be offenders, which merits study. Forum theatre (FT) is an experiential learning modality requiring a peer group to develop problem-solving strategies. FT was piloted to address mistreatment among residents. The objective was to determine whether FT was feasible, acceptable to resident learners, and could lead to self-reported changes in perceptions or behaviors, providing program directors a focused option to address professionalism as a competency. APPROACH: This initiative was conducted from September 2019 through February 2021 in obstetrics-gynecology and urology residencies at UT Health San Antonio and consisted of 3 phases: a focus group to identify mistreatment experienced by residents, resident volunteers to create and act out the FT scenario, and enactment of the FT scenario during didactic time. Residents completed anonymous retrospective pre- and postsurveys, as well as at 6-8 months after, to assess knowledge, attitudes, and self-reported and observed behaviors. Wilcoxon rank-sum tests and 2-sample t tests for proportions were used to compare variables between groups. OUTCOMES: The FT was completed successfully in both departments during didactic time. Twenty-six residents participated, 24 (92%) responded. Most respondents (23, 96%) would recommend FT to colleagues for teaching professionalism. Behavior changes were reported by 15 (63%) participants after the program. After 6-8 months, self-reported mistreatment behaviors had decreased, including "making fun of others" (15 (63%) to 10 (38%), P = .04) and sending "disparaging texts" (13 (54%) to 7 (27%), P =.02). NEXT STEPS: The use of FT during regularly scheduled didactic times was feasible and well received among residents. The evaluation demonstrated sustained self-reported behavior changes. Plans are ongoing to expand this approach to other medical specialties and professions institutionally.