Kyle C. Bohm,Tyler Van Heest,Terence J. Gioe,Julie Agel,Todd C. Johnson,Ann Van Heest

Background: Assessing orthopaedic surgery residency applicants is a complex process. One important applicant characteristic not commonly measured during the interview process is moral behavior, a key component of the guidelines of the Accreditation Council for Graduate Medical Education for professionalism competency. We sought to determine whether a relationship exists between the results of residency selection interviews, as measured by match rank order, and moral reasoning skills, as measured by the revised version of the Defining Issues Test (DIT-2).

Methods: The DIT-2, a psychological tool that has been validated in assessing moral reasoning in >30,000 subjects, was administered to orthopaedic surgery residency candidates on a voluntary basis during their interview day. Data were collected annually from four applicant classes (2009 to 2012) at one institution. Each candidate was interviewed by an orthopaedic faculty team and was ranked comparatively with the other interviewing applicants. The five-part aggregate interview method for ranking applicants for the match list included a focused interview station presenting ethical dilemmas as one part of determining rank order.

Results: One hundred and twenty-four fourth-year medical students interviewing for orthopaedic surgery residency were assessed with the DIT-2. The results from the DIT-2 produced a postconventional score, which correlates with various levels of moral development. Each applicant’s postconventional score was then compared with the patient’s overall rank order. Applicants had highly variable moral reasoning skills, with no relationship to the final rank list.

Conclusions: Despite a wide range of DIT-2 scores, the interview process did not differentiate applicants based on moral reasoning skills. It remains unclear whether the DIT-2 could (or should) be used as an additional data point to help stratify orthopaedic residency applicants and to predict their performance.

The orthopaedic residency application process is intensely competitive, and ranking applicants remains a difficult process. Each year, more than 99% of first-year positions are filled, yet numerous applicants go unmatched. To train the next generation of good clinical orthopaedic surgeons, it is crucial for residency programs to accurately assess orthopaedic residency applicants in the areas of intelligence, technical skills, and interpersonal skills. However, this goal remains elusive, as many common objective measures of medical student performance have low predictive value for future resident success

Residency programs currently grant interviews utilizing limited data points, including United States Medical Licensing Examination (USMLE) scores, medical school transcripts, and letters of recommendation. Although these measures may help quantify an applicant’s intellectual acumen and academic accomplishment, they fail to assess other important applicant characteristics. One important applicant characteristic neglected by these measures is moral behavior, a key component of the guidelines of the Accreditation Council for Graduate Medical Education (ACGME) for professionalism competency. Currently, moral behavior and professionalism are generally assessed through the interview process or other aspects of the application. As the presumed goal for every orthopaedic program is to train clinically competent orthopaedists with a high degree of professionalism, identifying candidates most likely to reach this goal using a quantifiable test of moral reasoning seems attractive. Poor professional behavior has been cited as the most common reason for resident dismissal from a program, suggesting that more attention to professionalism and moral behavior may be warranted.

Rest et al. formulated a comprehensive theory of moral behavior based on four psychological capacities: moral sensitivity, moral reasoning, moral motivation, and moral implementation. Moral reasoning skills are required when physicians consider conflicting personal opinions, government policies, resource allocation concerns, and the wishes of their patients and patient families. Although moral reasoning is only one component of moral behavior, it is an important and quantifiable measure

Rest et al. classified moral reasoning into three overlapping schemas: the personal interest schema, the maintaining norms schema, and the postconventional schema. These schemas represent moral reasoning strategies, and each individual uses these strategies in varying degrees when reasoning through moral dilemmas. The revised version of the Defining Issues Test (DIT-2) is a reliable and validated instrument using story-based moral dilemmas　developed by Rest et al. to quantitatively assess the degree to which an individual uses each moral schema. The results from the DIT-2 produce a score that correlates with various levels of moral development.