Introduction

The concept “emotional intelligence” (EI) was coined by P. Salovey and J. D. Mayer¹ in the early 1990s and popularized by D. Goleman² in 1995, with the publication of his book “Emotional intelligence: why it can matter more than IQ”; in his words, it is defined as: “the ability to recognize our own feelings and those of others, to motivate us and properly manage relationships”. It traditionally comprises 5 traits: positive outlook, emotional self-awareness, emotional self-control, social competence, and life skills and well-being.

Goleman promoted the study and use of EI in the corporate world; it was later disseminated in academic environments and was associated with leadership skills, better performance and job and professional satisfaction^2-5. It has been also associated with improved ability to cope with difficult tasks, challenges or stressful situations^6,7.

Over the past decade an increasing interest has emerged in the medical literature due to the natural relationship between EI and many of the non-technical skills needed among physicians. An iconic systematic review made by Arora et al.8 in 2010 found that higher levels of EI positively contributed to the doctor-patient relationship, increased empathy, teamwork, communication skills, stress management, organization, commitment and leadership. In addition, EI is a predictor of job satisfaction and psychological well-being among medical residents, and is inversely associated with signs of emotional exhaustion, depression and burn-out^9-12. Despite all this, much about EI in physicians has not been fully studied yet.

EI also increases with age in the general population and, in the business environment, with experience and level of training¹³.

There is some data suggesting that EI may decrease as physicians progress through their training¹⁴, although there are no prospective studies with longitudinal follow-up of EI over the entire course of the residency program to corroborate these findings. This decrease in EI may be due to depersonalization, desensitization and progressive burnout.

The development and teaching of non-technical and ethical skills during the residency program could improve EI and protect the physician against emotional exhaustion by improving his or her psychological wellbeing and, consequently, the care of the patients under his or her care.

Several research groups have evaluated the need for integrating EI traits into residency training programs; however, the pathways and methods for implementing them have not been defined yet^15-17. Before developing a program focused on improving EI, it is necessary to understand the basic characteristics of the target population, in our case residents in general surgery.

The aim of this study was to describe the psychometric characteristics of EI among residents in general surgery in Argentina and to analyze the effects of age, sex, scope of practice and postgraduate year level on it.

Material and methods

We conducted a prospective and analytic crosssectional study. The instrument used was the 30-item Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF v1.5), a self-report questionnaire developed and validated by the London Psychometric Laboratory at the University College of London (www.psychometriclab.com)^26,30, made up of four factors containing 13 facets and two independent facets are not keyed to any factor. The factors and facets are emotionality (trait empathy, emotion perception, emotion expression and relationship), self-control (stress management, low impulsiveness, emotion regulation), sociability (emotion management, assertiveness, social awareness, social awareness) and well-being (trait happiness, trait optimism, self-esteem).

The different factors are defined are interpreted as established in the original paper by Petrides¹³ et al.:

1. Emotionality: the individuals with high scores on this factor are in touch with their own and other people’s feelings. They can perceive and express emotions and use these qualities to develop and sustain close and significant relationships with others. The individuals with low scores on this factor find it difficult to recognize their internal emotional states and to express their feelings to others, which may lead to less rewarding personal relationships.

2. Self-control: persons with high scores have a healthy degree of control over their urges and desires. In addition to controlling impulses, they are good at regulating external pressures and stress. They are neither repressed nor overly expressive. In contrast, low scorers are prone to impulsive behavior and may find it difficult to manage stress.

3. Sociability: This factor differs from emotionality in that it emphasizes social relationships and social influence. The focus is on the individual as an agent in social contexts, rather than on personal relationships with family and close friends. Individuals with high scores on the sociability factor are better at social interaction. They are good listeners and can communicate clearly and confidently with people from diverse backgrounds. Those with low scores believe they are unable to affect others’ emotions. They are unsure what to do or say in social situations and, as a result, they often appear shy and reserved.

4. Well-being: high scores on this factor reflect a generalized sense of well-being, extending from past achievements to future expectations. Overall, individuals with high scores feel positive, happy, and fulfilled. In contrast, individuals with low scores tend to have low self-regard and to be disappointed about their life as it is at present. Factors and facets contribute to the global trait “emotional intelligence”. A 7-point Likert scale was used to score the responses, ranging from 1 or “strongly disagree” to 7 or “strongly agree”. We used the Spanish version (distributed in our language by the same laboratory, translated and validated by Pérez-González et al.). The survey was created in a Google Forms^® form along with other study variables: age, sex, postgraduate year (PGY) level (from PGY 1 to 5 or chief resident), province of practice and work setting (public or private institution). A brief cover letter was included at the beginning of the form explaining the aim of the study and encouraging the surgical resident to participate in the survey. The survey was distributed electronically via email and different social networks; it could be completed from March 1 to March 31, 2020. All residents in general surgery in Argentina were eligible to participate voluntarily and anonymously. The sample size was not calculated as this was an exploratory study. The global score and each factor/facet score were calculated using the online algorithm provided by the same laboratory on its website (psychometriclab.com/scoring-the-teique/).

Data were stored using a Microsoft Office Excel 2019 spreadsheet version 16.0. All the calculations were performed using IBM SPSS Statistics 23.0 software package. The Kolmogorov-Smirnov test was used to evaluate the normal distribution of the quantitative variables. Quantitative variables are expressed as mean (measure of central tendency) and standard deviation (measure of dispersion). Qualitative variables are presented as absolute frequencies and percentages. The Student’s t-test for independent samples was used to compare means between two groups. Onefactor ANOVA was used to compare means in more than three groups; post-hoc tests were performed with Bonferroni’s adjustment for multiple comparisons. The 95% confidence intervals are presented with the parameters, when necessary. A p value < 0.05 was considered statistically significant.

The study was approved by the Teaching and Education Committee of Hospital Italiano de Córdoba.

Results

A total of 156 surveys were responded. The surveys were sent to 42 residency programs and were responded by residents from 24 (response rate 57.14%). All these answers were included for the analysis. One-hundred and five (67.3%) survey respondents were women and 51 (32.7%) were men. Mean age of the sample was 29.02 ± 3.69 years (range: 25-49). The PGY level of the respondents was as follows: PGY-3, 45 residents (28.85%); PGY-4, 36 residents (23.08%); PGY- 1, 33 residents (21.15%); PGY-2, 30 residents (19.23%), and PGY-5 or chief resident, 12 residents (7.69%). Onehundred and fourteen (114) residents (73.08%) worked in private institutions and 42 (26.92%) in public hospitals. The other demographic variables are shown in Table 1.

Table 1 Demographic characteristics of residents in general surgery 

The mean global score for all the participants was 4.58 ± 0.89 Mean scores for each trait analyzed for all participants were as follows: well-being 5.02 ± 1.24; self-control 4.38 ± 1.02; emotionality 4.58 ± 1.06; and sociability 4.32 ± 1.18.

There were no statistically significant differences between sexes on the global score of EI or with any other factor or facet (Figure 1 and Table 2). Residents working in private institutions had a higher score on the trait emotionality versus those working in public hospitals (4.71 vs. 4.22) (Table 3).

Figure 1 Global scores of EI by postgraduate year level 

Table 2 Emotional intelligence among residents in general surgery (two-sample t-test for equal means) 

Table 3 Emotional intelligence among residents in general surgery by institution (two-sample t-test for equal means) 

The one-factor ANOVA showed statistically significant differences in the well-being dimension between the different PGY-levels (F = 9.72; gl = 4; p = 0.0001), particularly (after applying the post-hoc comparison with the Bonferroni’s correction) between PGY-1 and PGY-2 (p = 0.0001), PGY-2 and PGY-3 (p = 0.003), PGY-2 and PGY-4 (p = 0.0001), and between PGY-4 and PGY-5 (p = 0.03). In the emotionality dimension (F = 8.04; gl = 4; p = 0.0001) there were differences between PGY-1 and PGY-2 (p = 0.004), PGY-1 and PGY-3 (p = 0.0001), PGY-2 and PGY-4 (p = 0.04), PGY-3 and PGY-5 (p = 0.005) and between PGY-4 and PGY-5 (p = 0.0001). In the sociability trait (F = 3.17; gl = 4; p = 0.016), the differences were found between PGY-2 and PGY-4 (p=0.012). There were also differences in the global scores of EI between the different PGY-levels (F = 5.55; gl = 4; p = 0.0001) mainly between PGY-1 and PGY- 2 (p = 0.002), PGY-2 and PGY-3 (p = 0.04) and between PGY-2 and PGY-4 (p = 0.001). There were no statistically significant differences among the different PGY levels in the self-control dimension (F = 1.07; gl = 4; p = 0.37).

Discussion

EI encompasses many skills that are important for physicians in training. Nowadays, residents in general surgery require not only theoretical and technical knowledge but also interpersonal and communication skills, so that they can coordinate teams and interact effectively with their professional environment.

This is the first study conducted in the region that contributes to the literature for a better characterization of EI in general surgery residents^18-21. It confirms the findings of previous studies demonstrating the absence of sex differences in global EI among resident populations^{19- 21}. While previous studies have not shown sex differences among surgical residents in global EI (using multiple assessment tools), the surgical resident population in the study by McKinley et al. ¹⁹ demonstrated sex differences in the facets impulsivity (higher in women) and stress management (higher in men).

This work provides further evidence that, overall, sex is not a determinant of EI in populations of medical residents (Placek et al.²²).

We also agree with some published hypotheses that have tried to explain the low variability between sexes in surgical residents²³:

1. Residents in general surgery constitute a more homogeneous group of people than the general population.

2. They have decided to become physicians first and surgeons afterwards, so it is possible that people with the same IE traits will be grouped together in the same field.

3. All general surgery residents have undergone similar training, so perhaps some aspects of EI implicitly develop throughout the School of Medicine and residency program (it should be noted that many variables can affect EI).

Several previous studies have explored the association between age and EI among medical residents^{19- 21}. We did not find any correlation between age and any aspect of EI. The significantly higher score in the trait emotionality among residents working in private settings is striking (p = 0.006). We hypothesize that this could be due to the implementation of some measures of support and assistance to the resident (psychological cabinet, day of rest after 24-h shift, protected facilities for other activities, etc.). Such a hypothesis is not explored in this study and further research in the area will be needed to find a possible explanation.

When we explored the association PGY level and EI, we found differences in the global scores between the different PGY levels, mainly between 1 and 2, 2 and 3, and between 2 and 4 (as opposed to 2 recent publications that found no significant differences^22,23). When we specifically examined each facet, we observed that PGY-2 residents are at the lowest score in the facets well-being and sociability domains (this difference is statistically significant compared with the other PGY levels), and PGY-4 residents are at lowest score in the trait emotionality. Some of these facets could be associated with emotional or physical exhaustion, or depression. We strongly believe that this area deserves more attention. We could hypothesize that the decline in EI reflects the progressive psychic exhaustion of residents. There has not been a prospective follow-up of EI across the residency program in any previous study. Future research should focus on examining this trend over time and with a larger sample of residents. Although this study includes a significant sample of residents from a wide variety of settings and regions, it does not reflect the overall population of training programs.

The TEIQue-SF is a trait-based measure of EI and, therefore, the evaluation of TEIQue is a self-report of these traits. Some psychologists believe that EI should be considered a competence or “intelligence” that is best measured by an assessment based on the ability to solve or cope with a situation rather than by a survey²¹. However, the aim of this study was characterizing EI traits in a population of residents in general surgery; therefore, a trait-based assessment of EI is appropriate. TEIQue is also based on a Likert scale. Its exploratory nature is also a limiting factor for drawing conclusions. As with any Likert-like scale, it is difficult to know the impact of small differences in the scores in real life. For example, how does a person with a score of 4.5 manage emotions as compared with a person with a score of 4.0? Correlating scores of EI with other validated measures of depression, well-being, job satisfaction, communication, etc. could help to better define these questions.

Conclusion

Emotional intelligence is an attractive and effective model for defining and training future general surgeons in non-technical skills such as communication, teamwork and professionalism. Besides exploring the psychometric characteristics of surgical residents, we were able to show how several factors and facets (such as well-being and emotionality) vary throughout their training. Further studies will be needed to disentangle these findings using reliable instruments to assess associations between EI and physicians’ clinical and academic outcomes.