# Anesthesiology residents's professionalism perception in Curitiba and metropolitan region, Paraná, Brazil

Belize Keiko Arai, Diancarlos Pereira De Andrade, William Augusto Gomes de Oliveira Bellani

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Belize Keiko Arai, Diancarlos Pereira De Andrade, William Augusto Gomes de Oliveira Bellani. Anesthesiology residents's professionalism perception in Curitiba and metropolitan region, Paraná, Brazil. Revista Caderno Pedagógico - Lajeado - UNIVATES - Brasil, 2024, 21 (6), pp.e5303. 10.54033/cadpedv21n6-299 . hal-05004072

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# Anesthesiology residents's professionalism perception in Curitiba and metropolitan region, Paraná, Brazil

## Percepção de profissionalismo de residentes em anestesiologia de Curitiba e região metropolitana, Paraná, Brasil

## Percepción de profesionalidad de residentes de anestesiología en Curitiba y región metropolitana, Paraná, Brasil

DOI: 10.54033/cadpedv21n6-299

Originals received: 05/28/2024

Acceptance for publication: 06/18/2024

### Belize Keiko Arai

Master in Teaching in Health Sciences

Institution: Faculdades Pequeno Príncipe (FPP)

Address: Curitiba, Paraná, Brazil

E-mail: belize.arai@aluno.fpp.edu.br

### Diancarlos Pereira de Andrade

PhD in Applied Biotechnology

Institution: Faculdades Pequeno Príncipe (FPP)

Address: Curitiba, Paraná, Brazil

E-mail: diancarlos.andrade@professor.fpp.edu.br

### William Augusto Gomes de Oliveira Bellani

PhD in Dentistry - Public Health

Institution: Faculdades Pequeno Príncipe (FPP)

Address: Curitiba, Paraná, Brazil

E-mail: william.bellani@professor.fpp.edu.br

## ABSTRACT

**Introduction:** Professionalism has been gaining ground in Medicine. It includes constant updates in the medical field, professional confidentiality, good relationships with patients, family members and staff. **Objectives:** To analyze the level of professionalism among anesthesiology residents in Curitiba and its metropolitan region, Brazil. **Methods:** The Professionalism Assessment Mini-Exercise (P-MEX) professionalism assessment instrument was self-administered, in the translated and validated version for use in Brazil. A number of 94 invitations were sent via cell phone. A link was sent in which the P-MEX form was available. Data were recorded in a Microsoft Excel® spreadsheet and analyzed using descriptive statistics (Student's t test). **Results:** 39 responses were obtained (41.5% of the total number of contacts made). The population
studied was evaluated within the three Likert scale, that is, a level “within expectations” for professionalism competence. During the medical undergraduate years, when participants were divided into two groups and compared using the Student's t test, it didn't affect the results (p value>0.05). Unlike the R3 group, which, in the reflective skills dimension, self-assessment was lower than that of R1/R2, with p<0.05. In the type of care, those who worked exclusively with the Unified Health System [SUS], p<0.05 was evidenced in the doctor-patient relationship and reflective skills, with superiority in this group. Age had a significant impact (p<0.05) on the doctor-patient relationship, with older patients showing better performance. Conclusion: P-MEX can be useful in the teaching-learning process of professionalism, as it can promote reflection and contribute to the future anesthetist's commitment to society.

**Keywords:** Anesthesiology. Assessment. Medical Education. Professionalism.

## RESUMO

**Introdução:** Profissionalismo é um tema que vem ganhando espaço na Medicina. Inclui constantes atualizações na área médica, confidencialidade profissional, bom relacionamento com pacientes, familiares e equipe. Objetivos: Analisar o nível de profissionalismo entre residentes de anestesiologia em Curitiba e região metropolitana, Brasil. Métodos: Foi realizada a autoaplicação do instrumento de avaliação de profissionalismo Professionalism Mini-Evaluation Exercise (P-MEX), na versão traduzida e validada para uso no Brasil. 94 participantes da região de estudo foram convidados a participar, via celular. Foi enviado um link no qual o formulário P-MEX estava disponível. Os dados foram registrados em planilha no Microsoft Excel® e analisado por estatística descritiva (teste t de Student). Resultados: Foram obtidas 39 respostas (41,5% do total de contatos realizados). A população estudada avaliou-se na escala Likert três, ou seja, nível “dentro das expectativas” para competência de profissionalismo. Anos de graduação em Medicina, quando os participantes foram divididos em dois grupos e comparados pelo teste t de Student, não interferiram nos resultados (valor de p>0,05). Diferente do grupo de R3 que, na dimensão habilidades reflexivas, a autoavaliação foi menor que ao do R1/R2, com p<0,05. No tipo de atendimento, os que atuavam exclusivamente com SUS, p<0,05 foi evidenciado na relação médico-paciente e habilidades reflexivas, com superioridade deste grupo. Já a idade interferiu significamente (p<0,05) na relação médico-paciente, os de maior idade apresentaram desempenho superior. Conclusão: O P-MEX pode ser útil no processo de ensino-aprendizagem de profissionalismo, pois pode promover a reflexão e contribuir para o compromisso do futuro anestesista com a sociedade.

**Palavras-chave:** Anestesiologia. Avaliação. Educação Médica. Profissionalismo.

## RESUMEN

**Introducción:** El profesionalismo ganas espacio en la Medicina. Incluye actualizaciones en el campo médico, confidencialidad, buenas relaciones con pacientes, familiares y personal. **Objetivos:** Analizar el nivel de profesionalismo
de los residentes de anestesiología en Curitiba y su región metropolitana, Brasil. Métodos: El instrumento de evaluación de profesionalismo Mini-Evaluación de Profesionalismo (P-MEX) fue autoadministrado, en su versión traducida y validada para uso en Brasil. Se invitó a participar a 94 participantes por teléfono celular. Se envió enlace en el que estaba disponible el formulario P-MEX. Los datos se registraron en Microsoft Excel® y se analizaron mediante estadística descriptiva (prueba t de Student). Resultados: Se obtuvieron 39 respuestas (41,5% del total de contactos). La población estudiada fue evaluada en escala Likert tres, nivel "dentro de las expectativas" de profesionalismo. Los años de graduación en Medicina, cuando fueron divididos en dos grupos y comparados mediante la prueba t de Student, no interfirieron con los resultados (valor de p>0,05). A diferencia del grupo R3, que en la dimensión habilidades reflexivas la autoevaluación fue inferior a la de R1/R2, con p<0,05. El tipo de atención, los que actuaban exclusivamente en el SUS, se evidenció p<0,05 en relación médico-paciente y habilidades reflexivas, con superioridad en este grupo. La edad tuvo un impacto significativo (p<0,05) en la relación médico-paciente, mostrando los pacientes de mayor edad un mejor desempeño. Conclusión: P-MEX puede ser útil en el proceso de enseñanza-aprendizaje del profesionalismo, ya que puede promover la reflexión y contribuir al compromiso del futuro anestesista con la sociedad.

**Palabras clave:** Anestesiología. Avaliación. Educación Médica. Profesionalismo.

# 1 INTRODUCTION

The concept of professionalism is not defined and there is no single meaning for the term, it is a multidimensional concept and it is a word that is linked to culture. It includes constant updates in the medical field, professional confidentiality, good relationships with patients, family members and staff (Tsugawa et al., 2011; Holdefer et al., 2021; Façanha et al., 2023).

Therefore, its relevance in the process of training future professionals in Medicine (Berger et al., 2020) stands out and in order to facilitate this learning, both teaching and assessment can be used, with emphasis on the latter (Irby; Hamstra, 2016).

Professionalism can be assessed using a combination of clinical observation meetings, written exams, feedback from multiple sources, patient opinion, simulation, teaching activities, self-assessment compared to
assessment by others (Irby; Hamstra, 2016), and there is no ideal and universal model (Hodges et al., 2011).

The professionalism assessment instrument called Professionalism Mini-Evaluation Exercise (P-MEX) was presented in 2006. It emerged from a workshop of a development program in teaching and assessment of professionalism, at McGill University, in Canada (Cruess et al., 2006) and used the format of the assessment instrument that evaluates clinical skills in real scenarios, the Mini-Clinical Evaluation Exercise (mini-CEX), as a model (Norcini et al., 2003).

A set of 142 behaviors that reflected professionalism were identified. These were compiled into 24 items and grouped into four domains (doctor-patient relationship, interprofessional relationship, reflective skills and time management). Each of them is evaluated using a four-point Likert scale (4= exceeds expectations, 3= within expectations, 2= below expectations, 1= unacceptable). There is also a fifth assessment category, not applicable (NA), which is not scored. After an analysis of the 24 items, three were excluded due to redundancy, resulting in 21 items remaining for observation (Holdefer et al. 2020; Holdefer et al., 2021; Façanha et al., 2023).

The P-MEX was suggested to be applied in any situation where the behavior of the person evaluated (student, medical residents) can be observed, including consultations, internships and bedside visits. The assessment is based on interactions that frequently occur during resident training (Cruess et al., 2006).

The instrument has already been validated and applied in countries such as Brazil (Holdefer et al., 2021; Façanha et al., 2023), Japan (Tsugawa et al., 2011), Finland (Karukivi et al., 2015) and Iran (Jaffari et al., 2015; Amirhajlou et al., 2019), being recognized as a tool with the best measurement and scoring properties for evaluating medical professionalism (Cruess et al., 2006; Tsugawa et al., 2011; Li et al., 2017; Amirhajlou et al., 2019; Fong et al., 2020). Furthermore, it stands out for its wide acceptance and easy application, and can be used during direct observations of clinical encounters in real environments (Cruess et al., 2006; Tsugawa et al., 2011; Amirhajlou et al., 2019). Furthermore, analyzes of clarity, pertinence and relevance demonstrated significantly high
content validity indices in all evaluated items. These results confirm the suitability
of the instrument for use in the Brazilian contexto (Holdefer *et al.*, 2021; Façanha
*et al.*, 2023).

The article analyzed the level of professionalism among anesthesiology residents in Curitiba and its metropolitan region, Brazil, through the application of the P-MEX professionalism assessment instrument, in a self-assessment format.

## 2 METHODS

The P-MEX form was applied, in the self-assessment format, in the translated and validated version for use in Brazil (SPA, 2023). The research was carried out in a virtual environment with Anesthesiology residents in Curitiba and the metropolitan region. Residents of the first (R1), second (R2) and third (R3) years were contacted via cell phone messaging application and invited to participate through a link on Google Forms, in which the P-MEX form was available (Annex A). There were 103 vacancies occupied15 and 94 residents received the invitation. After accepting Informed Consent Form (ICF), the participant had access to the P-MEX professionalism assessment instrument.

A demographic questionnaire with information such as gender, age, time since training in Medicine, type of care provided (if only the Unified Health System-SUS, private or SUS/private) and year of residency in Anesthesiology was also collected (Annex A). Data were analyzed using descriptive statistics and comparisons between groups performed using the Student's t test. All analyzes were conducted using the R program, an open source and freely accessible software.

The project was evaluated by the Ethics and Research Committee of Faculdades Pequeno Príncipe, approved under opinion number 6,248,283, on August 18, 2023 and registered on "Plataforma Brasil", CAAE protocol number: 71745723.6.0000.5580.
## 3 RESULTS

The response rate was 41.5%, which means that 39 questionnaires, out of the 94 invitations sent, were returned. Of the responses, 18 (46.2%) were given by females and 21 (53.8%) by males; 12 (30.8%) for R1, 11 (28.2%) for R2 and 16 (41%) for R3. Among the research participants, 27 (69.2%) stated that they had less than four years of medical training, while 12 (30.8%) had graduated more than four years ago. Regarding age, 22 (56.4%) were under 28 years old and 17 (43.6%) over 28. Regarding the type of care provided in the medical residency program, 16 (41%) served only the SUS, one (2.6%) only had health insurance and/or private insurance, while 22 (56.4%) had access to SUS and/or health insurance/private insurance (Table 1).

<table><caption>Table 1: Sociodemographic data of research participants (n=39).</caption><thead><tr><th>Variable</th><th>Quantity n (%)</th></tr></thead><tbody><tr><td>Resident</td><td></td></tr><tr><td>R1</td><td>12 (30,8)</td></tr><tr><td>R2</td><td>11 (28,2)</td></tr><tr><td>R3</td><td>16 (41)</td></tr><tr><td>Resident (category)</td><td></td></tr><tr><td>R1 e R2</td><td>23 (59)</td></tr><tr><td>R3</td><td>16 (41)</td></tr><tr><td>Gender</td><td></td></tr><tr><td>Female</td><td>18 (46,2)</td></tr><tr><td>Male</td><td>21 (53,8)</td></tr><tr><td>Response time</td><td></td></tr><tr><td>1-5 min</td><td>35 (89,7)</td></tr><tr><td>5-10 min</td><td>4 (10,3)</td></tr><tr><td>Time since graduation (category)</td><td></td></tr><tr><td>=&lt;4 years</td><td>27 (69,2)</td></tr><tr><td>&gt;4 years</td><td>12 (30,8)</td></tr><tr><td>Age (category)</td><td></td></tr><tr><td>=&lt;28 years old</td><td>22 (56,4)</td></tr><tr><td>&gt;28 years old</td><td>17 (43,6)</td></tr><tr><td>Service</td><td></td></tr><tr><td>Health insurance/ private</td><td>1 (2,6)</td></tr><tr><td>Unified Health System [SUS]</td><td>16 (41)</td></tr><tr><td>SUS + Health insurance/ private</td><td>22 (56,4)</td></tr><tr><td>Service (category)</td><td></td></tr><tr><td>SUS + Health insurance/ private</td><td>23 (59)</td></tr><tr><td>Unified Health System [SUS]</td><td>16 (41)</td></tr></tbody></table>

Source: Authors, 2024.

The version applied in this study was the Holdefer's et al. (2020) version. The mean and standard deviation of each of the instrument's 21 items are
presented in table 2. The lowest value obtained was in question number 5 and the highest value was in question number 18.

<table><caption>Table 2: Data described from the P-MEX questionnaire items.</caption><thead><tr><td>Question</td><td>number of responses</td><td>mean score</td><td>Standard deviation</td></tr></thead><tbody><tr><td>Question 01</td><td>39</td><td>3.28</td><td>0.56</td></tr><tr><td>Question 02</td><td>39</td><td>3.31</td><td>0.61</td></tr><tr><td>Question 03</td><td>39</td><td>3.41</td><td>0.59</td></tr><tr><td>Question 04</td><td>39</td><td>3.26</td><td>0.59</td></tr><tr><td>Question 05</td><td>39</td><td>2.79</td><td>0.8</td></tr><tr><td>Question 06</td><td>39</td><td>3.26</td><td>0.55</td></tr><tr><td>Question 07</td><td>39</td><td>3.49</td><td>0.6</td></tr><tr><td>Question 08</td><td>39</td><td>3.46</td><td>0.55</td></tr><tr><td>Question 09</td><td>39</td><td>3.46</td><td>0.55</td></tr><tr><td>Question 10</td><td>39</td><td>3.15</td><td>0.78</td></tr><tr><td>Question 11</td><td>39</td><td>3.36</td><td>0.54</td></tr><tr><td>Question 12</td><td>39</td><td>3.23</td><td>0.54</td></tr><tr><td>Question 13</td><td>39</td><td>3.41</td><td>0.75</td></tr><tr><td>Question 14</td><td>39</td><td>3.56</td><td>0.55</td></tr><tr><td>Question 15</td><td>38</td><td>3.58</td><td>0.5</td></tr><tr><td>Question 16</td><td>39</td><td>3.26</td><td>0.64</td></tr><tr><td>Question 17</td><td>39</td><td>3.18</td><td>0.6</td></tr><tr><td>Question 18</td><td>39</td><td>3.72</td><td>0.46</td></tr><tr><td>Question 19</td><td>39</td><td>3.28</td><td>0.72</td></tr><tr><td>Question 20</td><td>39</td><td>3.44</td><td>0.6</td></tr><tr><td>Question 21</td><td>39</td><td>3.23</td><td>0.63</td></tr><tr><td>GENERAL</td><td>819</td><td>3.34</td><td>0.63</td></tr></tbody></table>

Source: Authors, 2024.

According to the four dimensions in which the 21 items were grouped, it is observed that the residents correspond, in a general view, to the professionalism aspect as they present an overall average score of 3.34 ± 0.63, which on the Likert scale means that meet expectations.

When analyzing the time spent training in Medicine, according to each of the four dimensions in which the 21 items on professionalism are grouped, it was observed that this time, whether greater than four years of graduation or less, did not interfere with self-assessed competence, with p values > 0.05 (Table 3).

<table><caption>Table 3: Mean score of questions – time since graduation in Medicine.</caption><thead><tr><td>Dimension</td><td>Mean score A</td><td>DP</td><td>Mean score B</td><td>DP</td><td>P* value</td></tr></thead><tbody><tr><td>Doctor/patient relationship</td><td>3.23</td><td>(0.67)</td><td>3.31</td><td>(0.6)</td><td>0.35</td></tr><tr><td>Interprofessional relationship</td><td>3.31</td><td>(0.62)</td><td>3.38</td><td>(0.58)</td><td>0.44</td></tr><tr><td>Reflective skills</td><td>3.36</td><td>(0.64)</td><td>3.32</td><td>(0.62)</td><td>0.62</td></tr><tr><td>Time management</td><td>3.51</td><td>(0.6)</td><td>3.53</td><td>(0.65)</td><td>0.91</td></tr></tbody></table>

Note: mean score A: <=4 years of undergraduate studies in Medicine. Mean score B: >4years.

DP – Standard Deviation. *Student's t-test (p < 0.05).

Source: Authors, 2024.
However, when comparing the groups of years of residence in which the students were specializing, the group composed of R1 and R2 showed a statistically significant superiority in relation to R3 in the “reflective skills” category, according to the version by Holdefer *et al.* (2020) (Table 4).

<table><caption>Table 4: Mean score of questions – groups R1/R2 and R3.</caption><thead><tr><th>Dimension</th><th>Mean score A</th><th>DP</th><th>Mean score B</th><th>DP</th><th>P* value</th></tr></thead><tbody><tr><td>Doctor/patient relationship</td><td>3.2</td><td>(0.67)</td><td>3.33</td><td>(0.61)</td><td>0.11</td></tr><tr><td>Interprofessional relationship</td><td>3.32</td><td>(0.64)</td><td>3.35</td><td>(0.55)</td><td>0.74</td></tr><tr><td>Reflective skills</td><td>3.44</td><td>(0.63)</td><td>3.22</td><td>(0.62)</td><td>&lt; 0.05</td></tr><tr><td>Time management</td><td>3.49</td><td>(0.58)</td><td>3.55</td><td>(0.65)</td><td>0.61</td></tr></tbody></table>

Note: Mean score A: R1 and R2. Mean score B: R3. DP – Standard Deviation

*Student's t-test (p<0.05)

Source: Authors, 2024.

Among the specializing students who provided assistance only to the SUS, they obtained higher scores in the dimensions “doctor-patient relationship” (3.38 ± 0.67) and “reflective skills” (3.48 ± 0.58) than the population that attended SUS and/or health insurance/private, with p<0.05 (Table 5).

<table><caption>Table 5: Mean score of questions – type of service.</caption><thead><tr><th>Dimension</th><th>Mean score A</th><th>DP</th><th>Mean score B</th><th>DP</th><th>P* value</th></tr></thead><tbody><tr><td>Doctor/patient relationship</td><td>3.17</td><td>(0.62)</td><td>3.38</td><td>(0.67)</td><td>&lt; 0.05</td></tr><tr><td>Interprofessional relationship</td><td>3.27</td><td>(0.6)</td><td>3.42</td><td>(0.61)</td><td>0.08</td></tr><tr><td>Reflective skills</td><td>3.26</td><td>(0.65)</td><td>3.48</td><td>(0.58)</td><td>&lt; 0.05</td></tr><tr><td>Time management</td><td>3.43</td><td>(0.63)</td><td>3.65</td><td>(0.56)</td><td>0.05</td></tr></tbody></table>

Note: Mean score A: SUS and/or health insurance/private. Mean score B: Unified Health

System (SUS). DP – Standard Deviation

*Student's t-test (p<0.05)

Source: Authors, 2024.

As well as resident doctors over 28 years of age, who presented a better self-assessment in “doctor-patient relationship”: 3.39 ± 0.63 with p<0.05. (Table 6).
<table><caption>Table 6: Mean score of questions – age of the participant.</caption><thead><tr><th>Dimension</th><th>Mean score A</th><th>DP</th><th>Mean score B</th><th>DP</th><th>P* value</th></tr></thead><tbody><tr><td>Doctor/patient relationship</td><td>3.16</td><td>(0.65)</td><td>3.39</td><td>(0.63)</td><td>&lt; 0.05</td></tr><tr><td>Interprofessional relationship</td><td>3.31</td><td>(0.59)</td><td>3.36</td><td>(0.63)</td><td>0.53</td></tr><tr><td>Reflective skills</td><td>3.34</td><td>(0.65)</td><td>3.36</td><td>(0.61)</td><td>0.79</td></tr><tr><td>Time management</td><td>3.55</td><td>(0.61)</td><td>3.47</td><td>(0.61)</td><td>0.47</td></tr></tbody></table>

Note: Mean score A: <=28 years. Mean score B: >28 years. DP – Standard Deviation

*Student's t-test (p<0.05)

Source: Authors, 2024.

## 3 DISCUSSION

Assessment can help the doctor in specialization acquire or improve professionalism competence, which can be carried out through written exams, reflection exercises, self-assessment, observations, feedback (Irby; Hamstra, 2016).

Assessing professionalism means determining whether apprentices have learned this skill and identifying early which deficiencies need to be worked on and adjusted to avoid, remedy and promote reflection on possible identifiable lapses in behavior not consistent with the profession (Jaffari et al., 2015; Findyartini; Sudarsono, 2018) in order not to compromise the relationship with the patient (Jha et al., 2014).

Some researchers used the 24-item version (Cruess et al., 2006; Jaffari et al., 2015; Amirhajlou et al., 2019; Kazemipoor et al., 2020) while others, including this study, used the 21-item version (Karukivi et al., 2015; Razzaq et al., 2019; Holdefer et al., 2021; Façanha et al., 2023). The initial research population studied was residents of Internal Medicine, Gynecology and Obstetrics, Psychiatry and Pediatrics (Cruess et al., 2006). Subsequently, other studies worked with residents from other medical specialties.

As for the evaluators, there was variation as well. This role was performed by preceptors themselves (Cruess et al., 2006; Jaffari et al., 2015; Amirhajlou et al., 2019; Kazemipoor et al., 2020), doctors, nurses, peers and residents themselves evaluating each other (Tsugawa et al., 2011; Razzaq et al., 2019), internship tutors, community members and students (Karukivi et al., 2015). Furthermore, the same participants were evaluated more than once in all the
studies mentioned and there was feedback at the end of most of them (Karukivi
et al., 2015; Amirhajlou et al., 2019; Holdefer et al., 2021; Façanha et al., 2023)
as in the original Canadian version (Cruess et al., 2006).

The instrument was initially proposed when the resident or medical student would be observed by a preceptor and they would give them a score based on their performance (Cruess et al., 2006). However, in 2015, a study was carried out that used the P-MEX as a professionalism assessment form in two ways: assessment by community members, internship colleagues, preceptors and through self-assessment. Next, the results were compared. It was the first time that the application of P-MEX in this self-assessment format was reported in the medical field (Karukivi et al., 2015).

The results found in this research, with residents in Anesthesiology in
Curitiba and the metropolitan region, produced similar results with a Finnish self-
assessment study (Karukivi et al., 2015). Other studies that used the P-MEX
instrument, but in the original format through application by observers also
presented similar outcomes.

In all of them, the global assessments were that the apprentices were
"within expectations", within score three on the Likert scale, which means that
students and residents of medical specialties meet expectations in terms of
professionalism.

In Canada, the global value was 3.257, the same value presented in Japan (Tsugawa et al., 2011). In Iran, the global score presented in the P-MEX was 3.32 ± 0.04 (Amirhajlou et al., 2019). Among Pediatrics residents, the global score was 3.63 ± 0.30 (Razzaq et al., 2019). In Brazil, the study with Pediatrics residents also obtained a score of 3.0 ± 0.42 (Holdefer et al., 2020) for all items. In this study, the value found was 3.34 ± 0.63, that is, similar to other studies.

And when the data obtained from the target population were subdivided
into four categories: doctor-patient relationship, interprofessional relationship,
reflective skills and time management, all values are within Likert scale three (3=
"within expectations") as well (Table 3).
Furthermore, this can help to avoid problems with medical misconduct and lawsuits, as most complaints against doctors refer to issues of conduct and not intellectual competence (Papadakis et al., 1999).

Item no.5 in Table 2 may have presented a score of 2.79 ± 0.8 due to the characteristic of the specialty Anesthesiology in Brazil, which ensures assistance to the patient during the anesthetic-surgical procedure in the operating room until transport to the post-anesthesia recovery room or to the Intensive Care Center (Bagatini et al., 2016).

In other studies that used the P-MEX to assess professionalism, only a few detailed the values attributed to each item on the form. The items with the lowest values found were “demonstrated awareness of limitations”: 3.14 ± 0.62 (Tsugawa et al., 2011), “requested feedback”: 3.03 (Razzaq et al., 2019) and 2.52+- 0.56 (Kazemipoor et al., 2020). This difference again can be attributed to the different cultural context of the studies (Karukivi et al., 2015), as the values of professionalism may not be the same in all societies and each one needs to customize these values according to local expectations (Du Preez et al., 2007).

Item 18 (“showed respect for colleagues”) of the applied version⁹ received the value 3.72 ± 0.46, the best self-assessment among the 21 items. It is important to highlight that Brazilian anesthesiologists work, for the most part, in the cooperative model, most of which are affiliated with the Brazilian Federation of Anesthesiologists Cooperatives. There are more than 20 cooperatives in the country (Bagatini et al., 2016). And, since the principles of cooperativism encourage cooperation between people, everyone’s participation in decisions, and work together to improve lives (Amorim et al., 2018), demonstrating respect for colleagues is a relevant and satisfactory result for the profession.

In comparison, the items best evaluated in other studies were: “actively listened to the patient” and “assisted the colleague” (this second item is not present in the 21-question version applied in the present study), evaluated with 3.35 ± 0,58 in both (Norcini et al., 2003). “Appropriate appearance” with 4.04 ± 0.14 (Razzaq et al., 2019); “avoided derogatory language” with 3.02 ± 0.31 (Kazemipoor et al., 2020). The items differed with this study. Note that the populations compared were Japanese, Pakistani and Iranian, again being able to
infer the cultural difference in local values (Du Preez et al., 2007; Karukivi et al., 2015).

When analyzing the time since graduation in Medicine, the time since graduation did not interfere with the professionalism of the participating sample, according to a statistical study. Comparison with other research cannot be made due to the lack of collection of this data in other publications.

This parallel also cannot be made when subdividing the sample into "residents over 28 years of age", who showed better performance in "doctor-patient relationship" with statistical significance (p<0.05), for the same reason as the lack of this category in the literature to date.

When the performance of the R3 group was analyzed with the R1/R2 grouping, the result found was that, in the "reflective skills" category, the performance of last year residents was lower, with a statistical value of p<0.05, the which contradicts the results of Salem et al. (2015). The Egyptian study compared R1, R2 and R3 of unspecified medical specialties and there was an increase in the 3rd year score overall, in the self-assessment model, arguing that there is an evolution in the perception of professional behaviors in professionalism with an increase in awareness of professionalism competence, reflecting a better assessment as the doctor's training time in specialization increases (Razzaq et al., 2019; Salem et al., 2015).

Finally, when divided into two groups regarding the type of care provided, those who only attended the Unified Health System [SUS], a public Brazilian health system that is based on principles such as integrality, equality and universality (Brasil, 1988), rated themselves better in dimensions "doctor-patient relationship" and "reflective skills" than those who provided assistance to the SUS and/or health insurance/private. When performing data analysis, these two dimensions presented a statistically significant result with p<0.05.

The study had limitations as it was not applied by external evaluators such as preceptors, peers, multidisciplinary team, community (Tsugawa et al., 2011; Karukivi et al., 2015; Amirhajlou et al., 2019; Razzaq, 2019; Façanha et al., 2023) but rather in a self-assessment format, as presented in the Finnish study. Therefore, the research only allowed us to know the level of professionalism of
the target population in terms of their own perception, which did not allow the extrapolation of data for comparative values with observers.

It should be noted that feedback was not provided in this present study despite its contribution to the learning of doctors in specialization by transforming assessment into learning (Vinagre; Tanaka; Tardelli, 2021).

The professionalism assessment process can help avoid behaviors that are not consistent with the student's role in Society (Jaffari et al., 2015) by promoting this self-reflection (Cruess et al., 2006; Passi et al., 2010).

Countries such as Canada and the United States of America (USA) address the topic in their curricula and have standardized assessment methods to evaluate it. In Canada, they occur through Entrustable Professional Activities (EPA), which are tools for evaluating performance in the workplace and in the USA the forms of evaluation are called Milestones, which assess competencies according to the resident's training and between they are professionalism. In Brazil, there is still no formal curriculum or standardized assessment of the term for Anesthesiology residentes (Vinagre; Tanaka; Tardelli, 2021).

A longitudinal study would also be worth carrying out to observe and monitor the evolution of professional behaviors (Kazemipoor et al., 2020) and this was demonstrated in research carried out with Dentistry students in the Netherlands, whose professionalism performances increased as the assessments were repeated throughout the year (Zijlstra-Shaw, Kropmans, Tams, 2005).

This instrument proved to be easy to apply (used in a real environment), quick to execute (completion time between 1-5 minutes), as described in the literature (Cruess et al., 2006; Façanha et al., 2023) and can be useful in contributing to reflection and learning about professionalism.

## 4 CONCLUSION

Teaching and assessment were identified as essential contributors to the resident physician's teaching-learning process. However, there is no
standardized model and no consensus on the best approach to assessing professionalism competence.

By promoting reflection, an assessment tool can prevent unprofessional behaviors, which can cause harm to patients and society, from being identified and corrected during training, thus helping the future anesthesiologist to commit to the same by following ethical standards of the profession.

The study carried out made it possible to evaluate the level of professionalism of anesthesiology residents in Curitiba and the metropolitan region, demonstrating that they self-assessed themselves on Likert scale three, indicating a level “within expectations” for the competence analyzed.

However, the study had limitations such as having been carried out cross-sectionally, not having been applied by observers and only a small sample of the population of Anesthesiology residents being evaluated. Additional research is recommended with a larger sample, assessments at different times that allow analyzing the resident's evolution, provision of feedback and application of the instrument by external observers.
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## ANNEX A

### PROFESSIONALISM ASSESSMENT INSTRUMENT PROFESSIONALISM MINI-EVALUATION EXERCISE (P-MEX) AVAILABLE FOR FILLING

#### PROFESSIONALISM MINI-EVALUATION EXERCISE (P-MEX)

Available: https://forms.gle/kiqGUvqHEPxqho5x7

Each of the items below must be scored between 1 and 4 according to the value established for each category:

Exceeded expectations (4 points). Within expectations (3 points). Below expectations (2 points). Unacceptable (1 point). Not applicable (N/A) (0 points).

<table><thead><tr><th></th><th></th><th>4</th><th>3</th><th>2</th><th>1</th><th>N/A</th></tr></thead><tbody><tr><td rowspan="7">Criterion 1 - Doctor/patient relationship</td><td>1. Actively listened to the patient</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>2. Showed interest in the patient as a person</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>3. Recognized and met the patient's needs</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>4. Goes the extra mile to meet the patient's needs</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>5. Continuity of patient care was ensured</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>6. Advocated in defense of the patient</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>7. Maintained appropriate limits</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td rowspan="5">Criterion 2 - interprofessional relationship</td><td>8. Demonstrated awareness of your limitations</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>9. Admitted errors and omissions</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>10. Requested feedback</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>11. Accepted feedback</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>12. Maintained composure in a difficult situation</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td rowspan="4">Criterion 3 - Reflective skills</td><td>16. Maintained appropriate appearance</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>17. Addressed your own knowledge and skills gaps</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>18. Showed respect for colleagues</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>19. Avoided derogatory language</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr></tbody></table>
<table><tr><td>20. Maintained patient confidentiality</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>21. Used health resources appropriately</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr></table>

<table><thead><tr><th>Criterion</th><th>4 - Time Management</th><th>4</th><th>3</th><th>2</th><th>1</th><th>N/A</th></tr></thead><tbody><tr><td>13. It was punctual</td><td></td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>14. Completed tasks reliably</td><td></td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr><tr><td>15. Was available to colleagues</td><td></td><td>☐</td><td>☐</td><td>☐</td><td>☐</td><td>☐</td></tr></tbody></table>

Time to respond P-MEX: ________ min

## Demographic profile of Anesthesiology residents in Curitiba and metropolitan region

Gender: ☐ F ☐ M Age: ________ Years of training in Medicine: ________

Year of residency in Anesthesiology: ☐ R1 ☐ R2 ☐ R3

Type of service (choose only one alternative):

☐ Health Unic System [SUS]

☐ Health insurance/Private

☐ SUS + Health insurance/Private