. _ . . F... RGU w. W . Nan}. .. o. m WSEUW wN .B .W m Hm... . . % Mu. .. “unmet kn .. . . . . . F... .M W“ .I U THO um "M .m Anmm.uuxncu v.99 .. L....3 F W m , 0 . . flag 9 E an. . .M an E T. H .mna C. mw.A I." I." GREGORY' moms LOFTUS 1975" llllll \ljllflll gm 1; l llljll w ill l, l L. LIBRARY Michigan State University Thislis to certify that the thesis entitled A MEDICAL ATTRIBUTION OF RESPONSIBILITY SCALE: EFFECTS OF OUTCOME, ACTOR, JUDGMENT CONTEXT, LOCUS OF CONTROL AND~OTHER PERSONALITY MEASURES presented by GRE GORY THOMAS LOFTUS has been accepted towards fulfillment of the requirements for 9M ‘E degree in Eg'¥c\v\fii “$7 DateE%1\)\qH 9' 0-7639 Ill :INDING av . HMS & SUNS 300K BRIBERY 4N9. . LIBRARY amoeRS - ‘ sniusrnnlmcmsn . JUL 1 1 2000 f ’1'] ABSTRACT x A MEDICAL ATTRIBUTION OF RESPONSIBILITY SCALE: ‘ EFFECTS OF OUTCOME, ACTOR, JUDGMENT CONTEXT, LOCUS OF CONTROL AND OTHER PERSONALITY MEASURES BY Gregory Thomas Loftus This research examined the patterns Of attribution of responsibility by medical school faculty and students to persons acting in a context of medical care and edu- cation. An instrument was developed called the Medical Attribution of Responsibility Scale (MARS) which syste- matically varied the Quality of outcome, Good-Bad; the Intensity of outcome, Mild-Severe; and, the degree of Association between actor and outcome, Direct-Ambiguous. The MARS consists of stories which describe situations likely to occur in the process of medical training. The stories describe the actions of either Student actors or Other medical personnel such as faculty or residents. The MARS presents two contexts for judgment: Causal attri- bution for some defined outcome, or Normative attribution associated with a type of behavior. Respondents rate the behavior of the actor as responsible on a sCale of 1-10, with 10 being most responsible. Gregory Thomas Loftus The results obtained in this study replicate and strongly support the effects reported by previous research, ‘with one exception. Attribution to authorities such as faculty was much greater than attribution to students. Direct Association between actor and outcome resulted in greater attribution than Ambiguous Association. Severe outcomes resulted in greater attribution than Mild out- comes. Stories with Good outcomes were given higher attribution than stories with Bad outcomes. This Good over Bad effect was the exception to the overall repli- cation. All the interactions among these outcome vari- ables, both two way and three way, were significant. The observation that Good outcomes were given higher attribution of responsibility than Bad outcomes was not predicted from previous research and was inter- preted as a reflection of the different context of judg- ment used in this study as contrasted to previous studies. The interaction between Severe and Ambiguous/Direct as previously reported was further explained through the three-way interaction which showed differences for Good versus Bad outcome conditions. The demonstration that Causal attribution resulted in lower scores than Normative attribution was reported here for the first time. Respondent characteristics also showed significant effects upon the attribution of responsibility. As pre- dicted, persons labelled Internal on a measure of Locus of Gregory Thomas Loftus Control attributed higher scores than Middles, while Externals attributed least. Overall, faculty and student respondents did not differ in attribution of responsibility. They did differ, however, in how much the outcome variables effected them such that students showed smaller differences for Good over Bad outcomes than did faculty, but students showed larger differences for Severe over Mild outcomes. An effort to relate responsibility attribution to a nomologic framework of interpersonal variables through the use of the Interpersonal Check List (ICL) and Attitude Toward Leadership (ATL) scale was unsuccessful. The non- significant multiple regression coefficients prevented development of an equation for predicting MARS scores from the ICL and ATL subscale variables in the sample for this study. The primary function of this research was the development of the Medical Attribution of Responsibility Scale (MARS). It was demonstrated to have test-retest reliability, yielding correlations ranging from 0.69 to 0.76 on a second administration of the scale six to nine months after the first. Validity was assessed through independent demonstration of the respondents' perception of outcome conditions. Validity is also sup- ported by the success with which previous research results were replicated with this instrument. The potential of this measure, and suggestions for its application in future research, are discussed. A MEDICAL ATTRIBUTION OF RESPONSIBILITY SCALE: EFFECTS OF OUTCOME, ACTOR, JUDGMENT CONTEXT, LOCUS OF CONTROL AND OTHER PERSONALITY MEASURES BY Gregory Thomas Loftus A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1975 DEDICATED TO BILL KELL His wisdom, patience, kindness, insight, tolerance, perseverance, simplicity, directness, and humor are sorely missed. I shall ever strive to pay dividends on the quantities of each which he invested in me. ii ACKNOWLEDGMENTS To all those who have made possible the completion of this research, and the process of education of which it was but a part, I would like to express my deepest gratitude. In particular, I would like to acknowledge the enduring, consistent, and salutary contributions of the Office of Medical Education Research and DevelOpment, each of its members, and especially Dr. Hilliard Jason, its first Director, and Arthur Elstein, the current acting Director. Without the cooperation of the members of the College of Human Medicine of Michigan State University, this research would not have been possible. The preparation of this manuscript has been guided and steadied by the time, energy, and faith of John M. Schneider, my mentor and friend. The scholarship of Henry Clay Smith and his graciousness in serving as acting chairman of my committee have been essential in preserving the progress of this study and its ultimate completion. Diana Lyon has figured importantly in this paper as in all my life. iii For an upbringing which has made the concept of responsibility a central theme in my life and my work, I am forever indebted to my parents and my family. iv TABLE OF CONTENTS Chapter I. INTRODUCTION AND REVIEW OF THE LITERATURE Three Functions of Responsibility . . Responsibility as a Personality Trait Responsibility as Causal Efficacy . Responsibility as Congruence with Standard 0 O C O O O O O 0 Literature on Responsibility as Per- sonality Trait. . . . . . . . Congruence with Standards. . . . . Responsibility as Causal Efficacy . . Attribution of Responsibility. . . Diffusion of Responsibility . . . Locus of Control . . . . . Locus of Control and Attribution of Responsibility . . . . . . . Responsibility and an Interpersonal Nomologic Net . . . . . . A Conceptualization of Responsibility. Development of Responsibility. . . Responsibility and Evaluation. . . II. STATEMENT OF THE PROBLEM. . . . . . Outcome Variables, I-E, and Amount of Attributed Responsibility . . . . Responsibility and a Nomologic Net. . III. METHODS AND PROCEDURES . . . . . . SllbjeCt—S O O O O O O 0 O 0 0 Instruments . . . . . . . . . MARS—-Deve10pment. . . MARS--Reliability and Construct Validity Page 11 12 14 15 20 23 27 28 33 38 41 46 49 49 53 53 56 Chapter Page Attitude Toward Leadership Scale . . . 61 International Opinion Survey . . . . 63 Design of the Study . . . . . . . . 66 Statement of the Hypotheses . . . . . 69 Analysis of the Data. . . . . . . . 70 Summary . . . . . . . . . . . . 71 IV. RESULTS 0 O O I O O O O O O O O 7 3 Effects of Story Variables. . . . . . 73 Summary of Results for Story Variables . 85 Respondent Characteristics . . . . . 88 Summary of Academic Level Effects. . . 92 Summary of Respondent Characteristic Effects. . . . . . . . . . . 97 V. DISCUSSION AND CONCLUSIONS . . . . . . 98 Part I The MARS O I O O O C O O O C O 99 Part II The Data on Attribution of ReSponsibility. 102 Quality of Outcome: Good vs. Bad. . . 105 The Interaction Between Intensity and Association . . . . . . . . 108 Part III Critique and Proposals . . . . . . . 108 Summary . . . . . . . . . . . . 111 Vi Page APPENDICES Appendix A. COMPOSITE PROFILE OF A "RESPONSIBLE PERSON" WITH SYNTHESIS OF CORRELATED RESEARCH FINDINGS AND CATEGORIZATION OF BEHAVIORS . . 112 B. STUDY INSTRUMENTS . . . . . . . . . . 118 C. VALIDITY STUDY ON MARS. . . . . . . . . 145 D. CORRELATIONS AMONG STORY VARIABLES. . . . . 158 REFEMNCES O O O O O O O O O O O O O O O l 59 vii LIST OF TABLES Predicted Order for Effects of Story Outcomes . . . . . . . . . . . Design of Controlled Study of Outcome and Locus of Control Effects Upon Attri- bution of Responsibility. . . . . . Dates of Test Administration to Respondents Perception of MARS Outcomes . . . . . Scoring Key for the International Opinion Survey 0 O O I O O O O C O O MARS Items Assigned to Variable Conditions Mean Scores for Attribution of Responsi- bility by Outcome Variables, Academic Level, and Locus of Control. . . . . Results of the ANOVA of Outcome, Academic Level, and Locus of Control Variables . Significant Interactions Among Story Out- come Variables . . . . . . . . . Design and Results of ANOVA Comparing Attribution of Responsibility in Causal Versus Normative Stories. . . . . . Design and Results of ANOVA Comparing Attribution of Responsibility to Student Versus Other Role Categories . . . . Significant Interactions Between Academic Level of Respondents and Story Outcome Variables. . . . . . . . . . . viii Page 42 44 52 57 65 68 75 76 82 84 86 91 Table 4-70 Standardized Regression Coefficients for Predicting MARS Scores . . . . Distribution Statistics for Multiple Regression Variables . . . . Components of Responsibility Identified by Various Research Teams . . . . Correlations Among Story Variables. ix Page 94 96 112 158 LIST OF FIGURES Figure Page 4-1. Effect of Quality of outcome, Good-Bad, on Attribut1on of ReSponsibility Scores . . . 78 4-2. Effect of Intensity of Outcome, Severe-Mild, on Attribution of Responsibility Scores . . 79 4-3. Effect of Degree of Association, Direct-- Ambiguous, on AttributIOn Of_Responsibility Scores . . . . . . . . . . . . . 81 CHAPTER I INTRODUCTION AND REVIEW OF THE LITERATURE A significant dimension in interpersonal evalu- ation is the degree to which an individual is perceived to be responsible. The concept of responsibility is the cornerstone upon which evaluation is based. Both praise and blame rest upon the assumption that a person can effect and be held responsible for the outcomes observed in his life. Accountability is derived from the concept of responsibility, and responsibility is an essential substrate of interpersonal trust. Responsibility is an important goal for some processes of training and edu- cation. In spite of its frequent use, the concept of responsibility is only poorly understood. The term "responsibility" occurs most frequently in contexts of evaluation or definition of relationships. A semantic differential analysis of the word "responsibility" showed that the associated constructs included trust- worthiness, competence, honesty, respectability, and maturity (Homant, 1969). In a list of 555 personality trait words, ordered according to their favorableness, responsibility was ranked 28th (Anderson, 1968). There are at least three primary functions to which the term ”responsibility" can be referred. Function I--responsibility can be considered as a personality characteristic. Function II--responsibility can be considered as the allocation of causal efficacy for some defined outcome. Function III--responsibility can be considered as the congruence between some specific per- formance and some standard of competence or ethics. These functions can be vividly grasped in terms of their context within normal language. The first function, responsibility as a personality trait, would sound like: ”You can count on John; he's a very responsible guy." The second function, allocation of causal efficacy, is frequently heard as an explanatory response. "Carol could not have moved that chair; Tom must have done it.“ Or, "The wind is responsible for that erosion." The third function, comparison to a standard, often reflects a role prescription: "The sergeant-at-arms is responsible for maintaining order." It can also be used to contrast observation and expectation, as in "Paul should not have left early; he was responsible for answering the phone until 5:00." The concept of responsibility reflects a complex interaction of these several functions. Complete specifi- cation of what constitutes responsible behavior in a given situation requires satisfaction of each of the terms in the formula--Agent X is responsible to whom, for what. Identification and exploration of these dif- ferent functions of responsibility has just begun. This study will review what has been accomplished and will seek to extend those findings into an area where they have practical importance--medical education. . Issues of personal and professional responsibility are an important concern within the College of Human 'Medicine at Michigan State University. Since its inception, this school has participated in deliberation and research seeking to clarify an understanding of the concept of responsibility. The ways in which a responsible personality is expressed, and how they might be assessed, is an important problem in the selection procedures leading to admission. The following is from the Admissions Criterion, Michigan State University, College of Human Medicine: Responsibility--The sense of accountability to and for an act or job. Knowing and recognizing that something has to be done and doing it without being told (this also ties into teaching). The factors which enhance the development of a sense of personal and professional responsibility need to be identified for inclusion in the curriculum. Pro- cedures are sought by which reSponsible performance in later practice can be predicted from school performance. Even the specification of criteria for defining the space that divides responsible and irresponsible behavior currently represents a significant problem in medical education. It is the purpose of this study to examine the applicability of findings from previous research on responsibility to the context of medical education and to progress toward an understanding of the concept of responsibility which is both more detailed and more com- prehensive. This will involve the replication of some previous research conclusions. It will also require the development of a valid and reliable measure based in the medical education field. It will additionally allow for the examination of the functional relationship of this concept with other dimensions of interpersonal functioning. Three Functions of Responsibility Responsibility as a Personality Trait Experience seems to indicate that some persons are more responsible than others. Some persons are said to be responsible in a way which implies that a rela- tively stable pattern of behavior, or personality char- acteristic, is typical of that person. Such a personality trait has been examined in the literature of psychology, especially by personality and developmental theorists. That research was reported and summarized in a previous work (Loftus, 1970) and will be briefly reviewed below. Responsibility as Causal EIficacy The degree to which persons actually control the outcomes in their lives continues to be a matter of debate (Wann, 1964). Most persons do act, however, as if outcomes reflect their own or other persons' actions. The degree to which an individual perceives himself to control the reinforcements in his environment has been shown to correlate with his behavior. His judgments of others might be similarly influenced by his expectations of their control of outcomes. The effects of such per- ceptions upon judgments of responsibility and their interaction with the characteristics of different out- comes have been examined. That research will be reviewed and certain conclusions selected for replication in this study. Res onsibility as Congruence wiEE Standara' An individual's assessment of another as respon- sible rests heavily upon the expectations he maintains. When such expectations are made of an individual because of a role which he occupies, they can be considered to constitute a standard which comprises the responsibili- ties of that role. For such a codification of expec- tations and the accountability function which is derived from it to operate smoothly, a prior understanding or consensus must exist between actor and judge and/or a mechanism for feedback must exist. Very little work has been done to date on the specification of such standards, at least within the field of medicine. In the pages that follow, previous research on the concept of reSponsibility and related topics will be reviewed. The research paradigms which have been used, and the measurement instruments they developed, will also be discussed. From the data thus presented, a comprehensive conceptualization of responsibility as briefly presented above will be synthesized and a proposal made to extend that understanding. The pro- posed research will attempt to extend the findings of previous research to problems of individual assessment and development of responsibility in medical education. Such an exercise shall test the validity of the constructs involved and will provide an opportunity for examining their interrelationships. Literature on Responsibility as PersonaIity Trait The perspective of personality trait theory dominates the early psychological examination of respon- sibility. In an earlier work (Loftus, 1970), a basic review of that research was Offered. In general, the paradigm for those studies was as follows: Present a definition of responsibility to a group of subjects; on the basis of that definition, have subjects select some associate or associates whom they consider to have demonstrated that characteristic in their social interactions; obtain from the subjects behaviors which they consider indicative of this responsibility char- acteristic: compile and consolidate these descriptions into a single profile of a “responsible person." Some research proceeded from there-~using the selection by associates as criteria, form groups rated as high or low on the responsibility trait, and obtain correlations with other measures. Such measures have included demographic or developmental profiles, and questionnaire responses to attitude surveys. Some of these attitude sur- veys were subsequently defined as scales for measuring responsibility. (Appendix A contains the comprehensive profile of a "responsible person," a synthesis of the research find- ings correlated with such a profile, and a categorization of behaviors considered indicative of that profile.) Several difficulties with that research can be identified. First, there was at best a limited agreement among different researchers as to the definition of the trait they were attempting to measure-~responsibility. Second, there was some difficulty with the high degree of association between measures of responsibility and more general ratings of the "good person." This "halo effect” was also demonstrated by high correlations between measures of responsibility and measures of social desir- ability. What emerged from these observations was a reflection of the importance of situational expectations of the judge upon ratings of responsibility. This led one researcher to conclude that responsibility appeared to be less a specific trait than a quality of adjustment to a situation (Harris, 1954). This extreme position is contradicted by most researchers but has special implications which will be discussed in later sections. The instruments which were developed by the above research became part of several personality inventories, including the Minnesota Multiphasic Per- sonality Inventory and California Personality Inventory. In general, however, such paper and pencil measures of responsibility showed only moderate correlations with interpersonal ratings and very low correlations with self-ratings. They were also characterized by limited reliability and limited developmental differentiation. They were group tests, dependent on large numbers of subjects and of little use for individual assessment or prediction. The major significant outcome of this work for the present study was the failure to produce an acceptably valid and reliable measure of the responsi- bility trait in individuals and its identification of the contribution of evaluation situation to judgments of responsibility. Congruence with Standards In examining the relation of given behaviors to judgments about the concept of responsibility, it became clear that some behaviors could be responsible from one point of view and not responsible or even irresponsible from another point of view. This reflects the under- standing that persons with different goals label acts responsible in terms of the relation between the act and the goal. That view can be formulated as--Behavior X is Goal A responsible to the degree that it leads to Goal A. Evidence of this principle was observed in earlier research (Harris et al., 1954; Havighurst & Taba, 1949) wherein obligations to school and family came into conflict. Responsible behavior was then related to the priorities assumed by the Judge. Recognition of this phenomenon led to an examination of the effect of role relations on the perception of responsible behavior. For a well-established role, such as physician, it could be tested whether persons with different relations to that role would express different expec- tations. The differential conceptions of physician 10 responsibility among medical subgroups were examined to make that test (Loftus, 1971). That study revealed that while there was great similarity in the categories of behavior given as examples and definitions of respon- sibility, reliable differences were Obtained across role groups. Patients, paramedical personnel, medical stu- dents, medical faculty, and practicing physicians each emphasized slightly different aspects of responsibility. Significant in its frequency as a definition of responsible behavior was the statement of the "golden rule"--do unto others as you would have them do to you. This statement carries the implication of some common set of Goals according to which specific behaviors might be judged. Or, it might be considered an algorithm for the evolution of such goals. As such, it reflects back to the conceptualization of reSponsibility as "quality of adjustment" which Harris proposed. An alternate algorithm may be derived from the experience of those frequently called upon to make judgments of responsi- bility (Saslow, personal communication, 1972). Interviews with such persons indicate that an important quality of those who are rated high on reSponsibility is that they establish interpersonal contracts characterized by a high degree of feedback. That is, persons rated high in reSpon- sibility are perceived as seeking and obtaining information about how their performance compares to the judge's 11 expectations. This familiarity with the judge's per- ceptions of his behavior, and the norms to which it is compared, allows the performer to improve his response- ability, and hence his ratings by the judge. The generalization of this type of situation, and the codifications of the expectations of judges, may be an important part of a program for developing responsi- bility. To date, the limited investigation of such patterns is found largely in social role analysis and is beyond the scope of this paper. It is clear, however, that there is no clear active conception of such standards within the field of medicine. Responsibility as Causal Efficacy The area of investigation of the concept of responsibility which currently receives the most attention in the psychological literature, and represents the leading edge of theory, deals with the perception of responsibility as the degree of causal control exercised by a person. Two such perceptions are immediately dis- tinguishable. One in which the actor is oneself and this area of inquiry is dominated by the construct of Locus of Control. The other, in which the actor is someone else, is best subsumed by the rubric Attribution of Responsibility. 12 Attribution of Responsibility An alternative to focusing upon responsibility as a personality trait is to examine the process of making judgments about the degree of responsibility demonstrated by another. Through a series of research efforts, it has been demonstrated that the degree to which one person holds another responsible for events in the interpersonal life space is a significant determi- nant of interpersonal behavior (Shaw & Sulzer, 1964). By "holds responsible," Shaw and Sulzer mean that the judge perceives the acting agent to be the cause of a given outcome. They established a direct linear relationship between the degree to which the judge per- ceives the actor to be the cause of the outcome and the degree or amount of responsibility the judge would attribute to the actor for that outcome. They also demonstrated that the perceived causality of the actor can be systematically influenced by several variables. Among the variables shown to influence the amount of attributed responsibility were: The degree of environmental determinism, as a :measure of an actors Association with the outcome. Five levels of Association were tested and can be briefly (described as follows: 1. The actor is associated with, but did not pro- duce, the outcome. 13 2. The actor produces an unforeseen and unintended outcome. 3. The actor produces a foreseen, but unintended, outcome. 4. The actor produces an outcome that is both foreseen and intended. 5. The actor produces a foreseen and intended out- come, but does so under coercion. The perceptual differentiation of the developmental level of the judge had a significant effect. As judges' character was shifted from young children to adults, increasing sophistication in differentiation of environ- mental determinacy was demonstrated. The amount of attribution became more distinctly different although the same directional increase maintained. Allied research (Shaw, Briscoe, & Esteve, 1968; Shaw & Schneider, 1967; Garcia-Esteve & Shaw, 1968; Sulzer, 1965) demon- strated other effects. The Quality of the outcome--good or bad--inf1u- enced amount of attribution such that negative outcomes resulted in greater amounts of attribution than did positive outcomes. Severe outcomes were shown to result in higher attribution scores than mild outcomes to define an figtensity variable. It was also demonstrated that less l4 responsibility was attributed when the actor was a child and that authorities received significantly more attributed responsibility (Mischel, 1961). Personal similarity to the actor lessened the amount of responsibility attributed by judges and increased the leniency of evaluative judg— ments in general (Shaver, 1970). The paradigm used by Shaw and Sulzer and their followers for.examining the relationships reported above involved the presentation of a series of stories to dif- ferent groups of subjects who acted as judges. In those stories, the variables mentioned above were systemati- cally varied across different combinations to produce the effects subject to statistical test. The preparation of the stimulus materials for that research is the proto- type for the paradigm to be used in the study prOposed by this paper and is elaborated in the methods section. Finally, after reading each story the judge would assign a simple numerical rating to reflect the amount of responsibility he attributed to the actor under that conflux of variables. Diffusion of Responsibility A related approach to the study of responsibility has examined the attenuation of perceived or attributed reSponsibility as a function of the number of persons involved in the circumstance. Wallach, Kogan, and Bem (1962, 1964) reported that decisions made by groups 15 showed greater attached risks than similar decisions made by individuals. Further evidence suggested that this effect could be outweighed by manipulation of such variables as the moral context of the decision, riskiness of the most vocal group member, or accurate knowledge of outcome probabilities (Bem, personal communication, 1970). The effect of diffusion has been dramatically shown and replicated in another series of experiments (Darley & Latane et al., 1968; Borofsky, 1970). These studies have shown that the more bystanders to an emer- gency, the less likely and/or more slowly any one bystander will act to intervene. They explain their results through an analysis of the thought processes of the bystander. "Is the situation a real emergency?“ The behavior of the other observers is used as a strong cue to decide, and their inactivity prolongs the ambiguity. "If it is an emergency, what can be done, and am I the best person to do it?" This decision also relates to his perception of the other observers. These self-directed questions are answered from the persons matrix of experience and self-perception. Perceived control over outcomes is one predominant vector in that matrix. Locus of Control The study of psychological aspects of causality and responsibility has been pursued under a wide range 16 of terminology. Brehm and Cohen (1962) discussed what they called volition, by which they meant the power for ”initiation and selection of behavior" and acceptance of its consequences. White's (1959) concept of "compe- tence" converges on similar variables. Schneider (1968) presents a review of related personality constructs which includes the ”feeling of efficacy" (Piaget, 1930), ”trend toward autonomy" (Angyal, 1941), as well as parts of the theory of Adler, Jung, Reisman, and Witkin among others. Indeed, a great portion of the theory and research on motivation can be considered relevant since the issues of control of behavior and outcome are central to such discussion. Of special interest is Heider's (1958) develop- ment of social learning theory and his formulations of social perception, power, origin, and causality. In addition to providing the original postulates of the study on attribution of responsibility covered earlier, Heider's work stimulated the investigation of control as a psychological construct. Led by Julian Rotter, a prolific stream of research has investigated the dimension of internal versus external locus of control in examining the perception of causal efficacy. In 1966 Rotter published his manuscript on generalized expectancies for internal versus external control of reinforcement. In that treatise he defined 17 a dimension of internal versus external as a function of the degree to which a person perceives the events in his life space to be a function of himself versus chance, fate, or powerful others. He developed the Locus of Control Scale to measure this characteristic and began a veritable deluge of studies--some 300 to date--which investigate the scores on such a scale in relation to behavior in a wide range of experimental conditions or to scores on other paper and pencil tests. The original scale has developed into multiple forms for different populations, and the underlying concept has been further differentiated. A recent review of the internal-external control construct offers the following summaries (Joe, 1971). The reliability measures of the I-E control scale have been consistent. Test-retest reliability reported by Rotter for varying population samples range from .49 to .83 across intervening time periods ranging from one to two months (1966). Hersche and Schiebe (1967) reported a similar range for a two-month time period. Harrow and Ferrante (1969) found a .75 test-retest reliability. Internal consistency measures ranged from .69 to .79 with nearly all in the .70's (Rotter, 1966). Several factor analytic studies of the I-E scale have indicated a need for further differentiation between 18 those aspects of a person's world view which indicate a personality trait and those which reflect societal norms (Dies, 1968; Gurin, Gurin, Lao, & Beattie, 1969; Lao, 1970). Despite this, the research findings to date tend to form a cluster which is logically and theoreti- cally consistent with the I-E construct. The findings depict externals in contrast to internals, as being relatively more anxious, aggressive, dogmatic, and less trustful and more suspicious of others; lower in self- confidence and insight; having low needs for societal approval; and having a greater tendency to use sensitiz- ing modes of defenses (Williams & Vantress, 1969; Feather, 1967; Hamsher, Geller, & Rotter, 1968; Miller & Mintion, 1969). Negroes and lower class individuals generally have more external scores than whites and middle class individuals. Data are consistent with the theoretical expectation that individuals who are restricted by environmental barriers and feel subjected to limited material opportunities would develop an externally oriented outlook on life (Battle & Rotter, 1963; Lefcourt & Ladwig, 1965, 1966; Scott & Phelan, 1969; Parsons, Schneider, & Hanson, 1970). Evidence for developmental antecedents of I-E is scarce. Individuals on the extreme ends of the I-E scale are more maladjusted than those in the middle 19 range. Pathological individuals tend to have higher external scores than do normal populations. An external expectancy of control can be shown to change toward an internal frame of reference after therapeutic inter- ventions and after resolution of crisis (Harrow & Ferrante, 1969; Smith, 1970; Gottesfield & Dozier, 1966; Gillis & Jessor, 1970). Externals describe themselves as more anxious, less able to show constructive responses in overcoming frustrations, and more concerned with fear of failure than achievement per se. Internals will not only show more initiative and effort in controlling their environ- ments but can also control their own impulses better than externals. Although there is some negative evi- dence, it seems that internals, in contrast to externals, show a greater tendency to seek information and adopt behavior patterns which facilitate personal control over their environments (Butterfield, 1964; Feather, 1967; Tolor & Reznikoff, 1967; Ray & Katahn, 1968; Phares, 1965; Seeman, 1963; Davis & Phares, 1967; Crandall, Katkovsky, & Crandall, 1965; Solomon, Houlihan, & Parelius, 1969). The notion that internals perform more effi- ciently under skill conditions while externals do better under chance conditions receives inconclusive support. Clearer evidence suggests that internals are 20 more cautious and conservative in risk-taking situations in an effort to control events. The hypothesis that internals are more resistive to perceived environmental manipulation is only partially supported, with data suggesting the influence of other variables (Liverant & Scodel, 1960; Minton & Miller, 1970; Schneider, 1968; Rotter & Mulry, 1965; Watson & Baumal, 1967; Getter, 1966; Strickland, 1970; Baron, 1969). In summary, while the findings are not remarkably consistent, the data from a bewildering array of experi- ments generally tend to support Rotter's contention that the internal-external control construct is a generalized expectancy which can be shown to have significant influence across many interpersonal situations. Locus of Control and Attribution of*ResponsibiIity The locus of control construct has been shown to represent a generalized expectancy of a person which reflects the degree to which he perceives the events in his life space to be subject to his control versus external factors such as fate, chance, or powerful others. The attribution Of responsibility represents a process in which individuals make judgments about the degree to which an acting person is held accountable for outcomes in the interpersonal life Space. A logical relationship can be proposed between these two variables 21 which would suggest that internals would attribute more responsibility to acting persons than externals in a projection of their personal expectancy. Such a relationship has been supported by recent research. Phares, Wilson, and Klyver (1971) demonstrated that in specific situations, internals attribute greater reSponsibility to themselves for the consequences of their own actions than do externals. In 1972, Phares and Wilson extended those findings to show a similar pattern, such that internals generally attributed more responsibility than did externals when attributing reSponsibility for an accident to a defendant in court action. This research also resolved a set of contradictory findings concerning the degree of attributed responsi- bility as a function of severity of outcome. Shaw and others' original research showed a significant increase in attributed responsibility as outcome severity increased. Walster (1966) found similar effects. However, support was not found in other experiments (Walster, 1967; Shaver, 1970). Phares and Wilson examined the stimulus stories used in the different studies and proposed the interaction of a variable based on the ambiguity versus structure of the story. This variable seems identical to the environmental determinacy variable noted by Shaw and Sulzer (1964). Phares and Wilson tested for this 22 interaction in their own research and in fact found that in cases of ambiguous degree of association between actor and outcome little responsibility was attributed with severe outcomes. However, when the cases were clearly structured in terms of the causal association between actor and outcome, attribution of responsibility significantly increased with severity of outcome. They also reported an interaction between I-E and attribution such that under severe ambiguous and mild structured conditions, internals attributed significantly more responsibility to the actor than did externals. In severe outcomes, they concluded that the direct structure appeared to outweigh the effects of the I-E variable. In mild ambiguous conditions there was also no observed difference between internals and externals. It is an unfortunate artifact of the research paradigm that Phares and Wilson's results cannot be directly compared to Shaw and Sulzers. The former researchers used stories presented in the context of a trial by juries and subjects were told the purpose was to study decision making in that context. Hence, subjects were role playing and even more significantly were attempting to emulate a process which is circum- scribed by special norms. In marked contrast, the Shaw and Sulzer stories were derived from common incidents 23 encountered in everyday living where the normal mode of interpersonal perception could be expected to dominate. It would seem that investigation of these effects of outcome intensity and of the degree of association between actor and outcome, and of their interaction with the I-E variable, needs further development. An additional contribution of the Phares and others' studies was the use of multiple measures of the attribution of responsibility. In addition to the simple scale rating of the amount of attributed reSponsibility, they had subjects impose monetary fine and propose re- educational service on the actors in their stories. They found that all meaSures were in the same direction for significance and that the simple scale rating resulted in the highest scores. Responsibility and an Interpersonal NOmologic Net The significant difficulties in defining and measuring responsibility as a personality trait have been previously discussed. Both the research on Attri- bution of Responsibility and Locus of Control have indicated, however, that the concept of responsibility has an important function in interpersonal behavior. The nature of that function remains to be defined. The theoretical consideration of that relationship rests 24 upon the development of a system for identifying the dimensions of interpersonal interaction. In a conceptualization of the dimensions of interpersonal competence, Smith (1968) presented a two- factor coordinate system based upon the constructs of Consideration and Responsibility. In this context, Responsibility is defined as the degree to which an individual feels and acts as if he were holding himself accountable for what happens in a situation or to a person. Consideration reflects the tendency to know and respect the rights and feelings of others. These ideas represent a distillation of research and theory from a wide range of sources. The writings of personality theorists, notably Erich Fromm (1956), presented the notion of a limited number of factors as defining the interpersonal space. From industrial psy- chology, the literature on leadership was culled to define two dimensions which were consistently found to account for much of the observed behavior (Fleischman, 1953; Dore, 1960). Developmental theory and research also contributed support (Schafer & Bayley, 1963). On the basis of empirical evidence, Smith sug- gests that the two dimensions of Consideration and Responsibility are independent; and he proposes that they constitute an orthogonal coordinate system into which other interpersonal factors might be mapped. 25 He characterizes the different quadrants as indicative of different interpersonal styles. Responsibility High Authoritarian Authoritative Consideration Low High Individualistic Permissive Low As a measure of the attitudes indicative of a person's position on these two dimensions, Smith pro- poses the use of the Attitudes Toward Leadership Scale (ATL). This scale is a 32-item forced choice inventory of possible behaviors which a leader can demonstrate. The scale yields a score for each dimension. The Attitudes Toward Leadership Scale (ATL) is a shortened version of the Leadership: Employee Orientation and Differentiation Questionnaire (LEAD) which was developed by Dore (1960). The LEAD questionnaire has been suc- cessfully tested for reliability and validity and used for the training and improvement of interpersonal skills. The evidence that two principle dimensions encompass a broad variety of interpersonal behavior has been forcefully presented by Hurley (1971). He 26 cites Allport's (1961) observation that a two-dimensional structure has been used for categorizing personality types into a comprehensive system since the time of Hippocrates. Factor analytic studies Of several psy- chological constructs have similarly resulted in two primary dimensions (Borgatta, Cottrell, & Mann, 1958; Burke & Bennis, 1961). The first Of these prepotent dimensions is labelled by Hurley as Acceptance versus Rejection of Others (ARC), after Symonds (1939) and Bierman (1969). The second dimension's most apprOpriate label is more controversial, but Hurley concludes that its most reasonable label might be Self-Acceptance- Rejection (SAR). Hurley further suggests that these two prepotent dimensions might be validly assessed by the two principle factors of the Interpersonal Check List (ICL) (LaForge & Suzek, 1955; LaForge, 1963). Validation that the two principle factors of the ICL present an orthogonal coordinate system which can be used to locate different personality types has been presented by Lange (1970). The ICL factors are desig- nated Dom and Lov and are calculated from individual item responses on the Interpersonal Check List (ICL). It is the thrust of Hurley's argument that an important step in the investigation of variables con- sidered to operate in the interpersonal space must be to define their relation to these prepotent dimensions 27 which have found such reliability across time and situ- ation. The reference of different variables to a relatively stable nomologic net offers significant opportunity to examine their relative importance and should provide for new insights of their interrelation- ships, providing valuable leads toward improved assess- ment and prediction. A Conceptualization of Responsibility The three functions of responsibility presented in the introduction reflect a conceptualization of the concept of responsibility as derived from the research just reviewed, the philosophical debate of centuries, and a formulation of the developmental learning process. Repeated instances of the use of the term "responsibility" have been examined for inclusion in one or the other of those functions. To date, they seem to represent a suf- ficiently comprehensive system. As a personality char- acteristic, common usage and the research discussed imply a relatively stable pattern of behavior which reflects the person's evaluation by others as showing a constel- lation of behaviors of which dependability has been shown to be predominant. The person shows consistency in meeting the interpersonal contract expected by others. As causal efficacy, responsibility involves judgments about the amount of control exercised over outcomes. 28 It can be self-referent, as in Locus of Control, or can refer to others as in the Attribution of Responsi- bility process. In either case, it has been demonstrated to influence the process of interpersonal behavior. Responsibility as congruence with a Standard defines the set of uses of that term which include references to competence or ethic and Often implies a codification of expectations with reference to a defined role. This function also allows for the treatment of behavior con- sidered irresponsible although that topic will not be taken up in this paper. On the basis of this conceptualization, a formula for defining responsibility involves the specifi- cation of the outcome, the actor, and the judge. Such a formulation can be expressed as--Agent X is responsible to whom, for what. Adequate definition of each of those terms allows for a satisfactorily Operational use of the term "responsibility." Development of Responsibility Research on the develOpmental antecedents of responsibility as a personality trait has been largely inconclusive. There was little support demonstrated for the principles of the folklore of child rearing which proposed that household tasks and firm parental discipline were needed (Bronfenbrenner, 1961). The antecedents of internal versus external have remained 29 similarly vague or undefined on the basis of the limited research reported (Joe, 1971). Understanding of the process of development of reSponsibility must therefore remain in the realm of theoretical speculation, derived from experience and what relations can be drawn from apparently relevant data, and bounded by the same factors. Such speculation will be offered here for the purpose of at least providing a framework from which hypotheses can be drawn for empirical test. This development rests mainly on the evolution of social perception in relation to learning theory and motivation. In his text, Personal Causation, Richard de Charms (1968) provides a review of psychological theories of motivation. From this he develops a conceptualization of the construct of causality based upon developmental self-awareness and the special qualities inherent in the perception of persons, as opposed to objects. He describes the absence of any empirical justification for the concept of causality since physical events can only demonstrate contiguity either temporal, physical, or both. Contingency remains an inference, usually based on statistical probabilities and/or experience of that contiguity. deCharms postulates that the notion of causality evolves from self-awareness of intention. As a child becomes aware of its efficacy in achieving changes in its environment as a function of intended 3O effort, it develops the idea of itself as origin or cause. In making an intended effort and achieving an intended outcome in the environment, a person develOps a sense of responsibility or accountability for that outcome. Person perception includes an awareness of other persons as similarly capable of such intended effort and leads to similar perceptions of such persons as responsible for outcomes in the environment. The theoretical development prOposed by deCharms provides a context for understanding both the locus of control construct and the process of attribution of responsibility. It also suggests the nature of their demonstrated interrelationship. Support for this theory can also be drawn from other research. An ingenious comparison was performed by Seligman (1969) in a series of studies with dogs which examined the consequences of different learning or conditioning paradigms. He demonstrated that dogs trained first in a classical conditioning paradigm exhibit a char- acteristic he termed "induced helplessness" when trans- ferred to a training context of an operational con- ditioning paradigm. Specifically, in the classical conditioning sessions the dogs were taught that the onset of a buzzer preceded administration of a shock. The classical conditioning paradigm does not allow for the animal to have any control over the outcome, and the 31 dogs received the shock at a set interval. After such training, the dogs were transferred to a jump box, which meets an operational conditioning paradigm. Here too the onset of the buzzer precedes administration of an electric shock. In this paradigm, however, the dog can exercise some control over the outcome by jumping from one side of the box to the other prior to the onset of the shock. Unlike naive dogs, the dogs trained in the classical paradigm exhibited the induced helplessness which maintained their presence to shock. They did not exercise the control that naive dogs quickly learned. In fact, in order to get the dogs to move away from the shock, Seligman had to completely remove the jump barrier, attach a rope to the dog's neck, and drag it across to the safe side. It took a replication of this procedure as many as 60-100 times before some of the classically conditioned animals learned that they could exercise control to avoid the shock. In terms of the constructs previously discussed, having learned a com- pletely external locus of control, it was difficult to train the animals toward an internal locus. In contrast, dogs trained first in the internal locus setting of the operational paradigm endured the classical paradigm but were able to re-assume an internal locus when the situation allowed. These data clearly point to early 32 experiences as important for the establishment of locus of control expectancies. Material derived from clinical psychology on the develOpment of psychopathology also suggests the importance of early learning about the locus of control. The so-called schizophrenigenic mother or family is characterized by a communications pattern which prevents a child from experiencing reliable associations between its own behavior and environmental outcomes. It could be said to thus foster the development of an external locus of control perception. Having once learned that locus, the child might be typified as failing to exercise control, even when it is possible. Such behavior is typical of adult schizophrenics. Related to this idea also is clinical data and research on depression. The classical statement of the depressive syndrome might be "it doesn't matter what I do": A clear statement of a perception of external locus of control. The frequent association of depression with outcomes which in fact are under external control, such as the death of a loved one or other irreplacable losses, is entirely consistent with the theory. SO also is the most successful form of treatment-~activities which rein- force an internal locus again. Perhaps the most significant support of deCharms postulated develOpmental sequence comes from Piaget's 33 (1965) meticulous elucidation of the child's concep- tualization of causality and his own theories derived from that data. The features of projection and the assumptions of similarity which are demonstrated both for other persons and objects fit the theory. The beliefs of primitive tribes have been shown to operate upon similar projections of causal efficacy upon objects both real and conceived. Finally, the effects of the developmental level of the judge in terms of differen- tiation of the different levels of causal determinacy which was demonstrated by Shaw and Sulzer (1964) implies a developmental scheme consistent with deCharms' theory. It is worth noting that this theory of the development of responsibility is derived within the context of interpersonal communication. The importance of feedback and/or verification of expectation and per- formance is crucial. This same operation, of establishing an interpersonal contract which provides for such feed- back, may become a more successful substance with which to work toward the assessment of responsibility as a personality trait. Responsibility and Evaluation The most common context in which the term ”responsibility" is used has to do with defining or evaluating a relationship. It is especially clear in dealing with the evaluation of an individual's 34 performance in his role. For most roles, some consensus exists about the duties or responsibilities which it encompasses. For a few, there is a clear specification of the standards and the criteria by which specific per- formances can be compared. Certainly, the clearer the standard and criteria are expressed, the easier it is to evaluate the degree of responsibility met by a person's performance. The terms of the formula--Agent X is reSponsible to whom, for what--are defined. Within the context of education, the process of assessing a person's performance can be more complicated. To the degree that the educational process is designed to prepare the student to adequately fulfill the respon- sibilities of a professional role, he cannot be expected to demonstrate such performance until the relevant educational processes are accomplished. Observation reveals that, in fact, students are not usually expected to portray adequate role performance. The process of observation, practice, supervised performance, and finally independent performance has intuitively and explicitly been a part of education by long tradition. At different stages of the educational process, the student is in fact held accountable not for professional role performance, but for a series of enabling per- formances concerned with motivation, attention, partici- pation, and mastery of certain building blocks upon which the final professional performance rests. 35 Confusion can arise from this process, however. It is unfortunately the case that there is no perfect or even linear prOgression from responsible performance of the tasks of a student to the tasks of the profes- sional. In fact, within medicine it can be argued that there is no such progression. Performance in early medical school, as measured by grades or certified exams, is totally unrelated to performance in either the clinical years or subsequent practice as measured by the judgments of observers in the clinical setting. It would seem there has been some confusion of the standard to which the student's performance should be compared in evaluating his preparation to meet profes- sional reSponsibilities. The evaluation of responsibility can be improved by the clarification of the standards to which a per- formance is compared. In combination with the development of educational objectives, the use of the Mastery Model as presented in the Keller plan (1974) for instruction is most consistent with this goal. The Mastery Model (Ways, 1970) simply re-instates the practicing pro- fessional as the standard to which a student's per- formance is compared. This process also allows for a greater freedom in the enabling performances which can be accepted as legitimate and assesses their adequacy in terms of their success in moving the student toward 36 the Mastery standard. Behavior X is Goal A responsible to the degree that it leads to Goal A. By analogy, the assessment of responsibility emphasizes the desti— nation rather than the path used tO get there. It is a corollary to the Mastery Model that evaluation of the progress toward professional standards must make it clear to the student what parts of those standards he has matched. Subsequent to such matching, he is assumed to be able to continue such performance. This allows for resolution of the question of whether a given substandard performance reflects ability or some combination of other factors. Having performed to ade- quate standards for evaluation, the student has demon- strated ability, i.e. causal potency has been established. When failures to meet the standards are observed, the student can be held accountable for the different allo- cation of his established resources in terms of attend- ing to some other set of priorities, or standards. When an individual is examined for the purpose of assessing his performance of his responsibilities, it often becomes clear that there are conflicts among several specific objectives which prevent his adequate performance of them all. Under such circumstances, a set of decision rules are often evolved which assist the person to select a best resolution of the observed conflict. These decision rules reflect a system of 37 priorities or a hierarchy of values. Such hierarchies are seldom presented to the novice in any coherent form. Rather, they are implied in a variety of experiential contexts, and their formulation is left to the indi- vidual. This condition is the result of, and a factor which maintains, the lack of consensus on standards which would assist the ultimate identification of responsibility. Such formulations become a necessary step in the process of defining the concept of responsi- bility in medicine. For the present they must constitute the grounds for debate which may generate a clearer understanding of responsibility, its operations, and realistic measures. CHAPTER II STATEMENT OF THE PROBLEM The operations of the concept of responsibility within the field of medicine have not been well defined. It is the purpose of this study to examine, within the context of medical education, some of the conclusions which have been drawn from research on responsibility in other settings. In addition to providing a replication of that research, this study will add a significant dimension of practicality to the constructs involved. As discussed in the review of the literature, additional investigation is especially required to resolve conflict- ing results dealing with the interaction of several variables. The situational variables of outcome intensity and degree of association between outcome and actor have shown contradictory findings. Their interaction with the locus of control variable was also found to be con- stricted. The effects of each of these variables on the amount of responsibility attributed will be re-examined. This study will define situations in medical education 38 '1 39 and use medical students and faculty as actors and judges to re-examine the conclusions of previous research. In order to accomplish this translation, an instrument is required which describes medical contexts for responsibility judgments. Such an instrument must contain systematically varied presentations which cross the levels of outcome direction and intensity as well as degree of association between actor and outcome. In addition to the above variables which relate to the responsibility function of causal efficacy or control, investigation of the function of responsibility as con- gruence with a standard should be included in order to begin the integration of the several identified functions of responsibility. The latter function, comparison to standard, would involve the presentation of situations which require the judge to compare the behavior of an actor to the judge's personal standards of normally or exceptionally responsible behavior, without reference to a specific outcome for the performance. The develOpment and trial of such an instrument constitutes the primary function of this study. The second major thrust of this research reflects the need to deal with the concept of responsibility as a portion of a more comprehensive understanding of interpersonal behavior. Toward this end, the specific 40 measures of responsibility functions must be related to other measures which can be used to define a nomologic net for interpersonal behavior within which a more compre- hensive and unified discussion can occur. The theoretical coordinate systems upon which the Interpersonal Check List (ICL) and the Attitudes Toward Leadership (ATL) are based offer such a framework for encompassing the inter- personal space. In addition to broadening the discussion of responsibility, the inclusion of the ICL and ATL in this study represents a step toward the model of a multi-trait multi-measure theory proposed by Campbell and Stanley (1963). Clearly, responsibility represents the kind of complex concept for which such an approach is most appropriate. Inclusion of the variables assessed by the ICL and ATL also provides a step toward the reinte- gration of the function of responsibility as a personality trait. It is the second function of this research to examine the position of the concept of responsibility within a nomological net which defines the interpersonal space. The problem analysis can now be reformulated to provide more operational statements for the conduct of the study. Parts of the problem will be identified, and the questions to be asked of the data will be derived. 41 Outcome Variables, I-E, and Amount of Attributed Responsibility Several variables have been shown to effect the amount of responsibility attributed to an actor in a given situation. Shaw and Sulzer (1964) found that bad outcomes resulted in greater attribution than good out- comes. This variable is here after called Quality of outcome, good vs. bad. They also found that severe out- comes resulted in greater attribution than did mild out- comes. This variable is called Intensity of outcome. This latter effect was found to be modified by the directness of association between actor and outcome by Phares and Wilson (1972) who did not include the direction variable. The inconsistency between these two research efforts was complicated by different research paradigms. While Shaw and Sulzer used occurrences from everyday life, Phares and Wilson used an occurrence presented as a jury trial and asked their subjects to role play in making their responses. In order to resolve the uncertainties left by the differences noted above, the effects of the degree of association between actor and outcome will be re-examined. This variable will be called Association and shall be presented in a binary condition of ambiguous or direct association between actor and outcome. The paradigm for this research will parallel that of Shaw and Sulzer. In contrast to Wilson and 42 Phares role-playing situation, in which they attempted to bring a personal involvement of the subjects into the experiment by manipulating their similarity to the actors in the jury case, this study will present stories in which the judges are personally involved by virtue of their daily lives. The effects of the variables will be examined in a medical context in which medical students and faculty act out incidents which the judges are likely to meet in their own lives. Thus the participants will not role play but will in fact be asked to express on this instrument the judgments encountered in their own interpersonal space. The variables to be presented in the stories of this instrument will be the outcome variables of Quality, Intensity, and Association. A complete crossing of these variables results in the formation of eight cells as depicted below. Table 2-1 Predicted Order for Effects of Story Outcomes Ambiguous Direct Severe Mild Severe Mild Good 4 Bad 5 2 43 In each case, the predicted direction of the results is indicated by underlining the direction of the variable which is expected to result in the greatest attribution of responsibility. The numbering within the cells indi- cates an expected ordering of the amount of attributed responsibility under those conditions with 1 being least and 8 greatest. In addition to the effects of outcome variables, the differences in paradigm used by Phares and Wilson leave the operation of the locus of control construct in nonrole-playing contexts uncertain. To explore this, the relation between I-E and outcome variables will be re-examined in this study using the instrument which shall henceforth be called the Medical Attribution of Responsibility Scale (MARS). Defining Story as one major effect and I-E as another allows the creation of the diagram on page 44. Story conditions are ordered according to the previous diagram. Three groups are defined for the I-E variable. The Medical Attribution of Responsibility Scale (MARS) will be used to obtain scores on the attribution of responsibility for stories which represent a com- pletely crossed presentation of the outcome variables Direction, Intensity, and Structure. The Locus of Con- trol construct will be measured by a newly developed form of the I-E Scale. The questions to be asked of these data are as follows: 44 Hmcuwuxm Houusoo manta: , mo msooq accumucH .uomuflo .mabfid .uomufio .mflnfid .uomufio .mHnE< .uoouflo .maa84 mum>mm oum>mm cafiz can: mum>mm mum>mm was: sad: cam cam smm cam woow noou oooo coco m s m m v m m a Nuoum huflawnwmsommmm mo soausnwuaud comb muomwmm Houusou mo msuoq can msoouso mo ausum omaaouucou mo cmflmmo Nam manna 45 Does the variable of outcome Quality exert a sig- nificant influence upon the amount of attribution observed in a medical setting? Does the variable of outcome Intensity exert a significant influence upon the amount of attri- bution observed in a medical setting? Does the variable of outcome Association with actor exert a significant influence upon the amount of attribution observed in a medical setting? Does the variable of judge's locus of control exert a significant influence upon the amount of attribution observed in a medical setting? Do interactions among these variables occur which exert a significant influence upon the amount of attribution observed in a medical setting? Do faculty and students differ in the amount of attribution or pattern of interactions? Do differences exist in attribution for a spe- cific event's outcome and for a general behavior? Do differences exist in attribution to different groups of actors? 46 Responsibility and a Nomologic Net No previous study has reported on the relationship between the concept of responsibility and a nomologic coordinate system for interpersonal behavior, except the proposition by Smith (1963), that responsibility be used to define one dimension of such a system. The existence of prepotent dimensions offers an opportunity for addi- tional examination of such relationships. Smith's con- ceptualization presents Responsibility and Consideration as two orthogonal factors of a coordinate system. An alternative conceptualization, summarized by Hurley (1971), presents Acceptance-Rejection of Others (ARO) and Self- Acceptance Rejection (SAR) as alternative dimensions for such a coordinate system. Acceptance Rejection of Others (ARO) can be assessed by the Interpersonal Check List (ICL) factor of Dom. Self-Acceptance-Rejection is assessed by the ICL factor of Lov. The similarity between the constructs of Responsi- bility as used by Smith and the Dom factor of the ICL suggest that there may be a strong correlation between scores on these two scales. Likewise, Lov and Consider- ation can be expected to have a strong relation. By administering both these instruments to the same group, an estimation of their similarity will become readily available. In addition, the two different instruments can be compared to establish a stable system of 47 coordinates for locating more specific measures of responsibility function. Thus, comparisons can be made not only between the Interpersonal Check List scores and scores on the Attitude Toward Leadership scale, but similar comparisons can be made with scores on the Locus of Control scale and scores of the Medical Attribution of ReSponsibility Scale. The questions to be asked of the data gathered from the Interpersonal Check List (ICL), the Attitudes Toward Leadership Scale (ATL), the Locus of Control scale (I-E), and the Medical Attribution of Responsibility Scale (MARS) are as follows: 1. Do the scales of the ICL and ATL correlate highly enough that they can be considered to define the same coordinate system of interpersonal behavior? 2. If so, what is the unique contribution of each? 3. If not, what are the observed differences? 4. If not, what are the relationships between the two systems? 5. Does Locus of Control correlate significantly with any of the four scales defined by ICL and ATL to indicate a special relationship, or can the scales be used to locate different scores on the locus of control construct within dif- ferent quadrants of the coordinate system? 48 Do scores on the Medical Attribution of Responsi- bility Scale (MARS) correlate significantly with any of the four scales defined by ICL and ATL to indicate a special relationship, or can scores on the MARS be used to locate persons in dif- ferent quadrants of the coordinate system? Can a regression equation derived from these several scales be used to predict scores--on each other?-—on other psychometric instruments?-—inter- personal behavior or ratings? CHAPTER III METHODS AND PROCEDURES This chapter includes the presentation of details on the conduct of this study. The participants are identified. The instruments used to measure the several variables are described, and the character of tests is given. The design of the study is proposed, and the hypotheses to be tested are stated. The analyses of the data are identified. Finally, a summary is provided. Subjects Members of the College of Human Medicine at Michigan State University responded to the different test scales for this study in cooperation with a project identified with the Office of Curriculum Implementation and the Dean for Student Affairs Office. All participants were invited to assist this project through cover letters signed by the Associate Dean. (Copies of those cover letters are included in Appendix B along with copies of each of the instruments used.) The faculty identified as the sample for this study were those acting as small 49 50 group leaders during Phase I, in fall quarter 1972. This sample included Ph.D.'s from both biological and behavioral sciences as well as M.D.'s. It also included the upper class students who were acting as co-faculty in the group exercises that term. Student samples were the members of the entering classes of 1972 and 1973. The 45 faculty were asked to complete the Inter- national Opinion Survey during April of 1973 and to respond to the Attitude Toward Leadership Scale, the Interpersonal Check List, and the Medical Attribution of Responsibility Scale during July 1973. The 85 stu- dents of the 1972 entering class were asked to complete the ATL, the ICL, and the MARS during May 1973. They had completed the 108 as part of a battery of tests taken during an orientation period at the beginning of fall term. The 90 students entering in 1973 took the four measures for this study as part of that same Entry Profile battery in September 1973. All respondents were identified only by a confidential code number which the experimenter could not associate with names. Of the 45 faculty in the sample, 34 sets of data with scores on all four measures were collected and put into analysis. From the 85 members of the 1972 entering class, 71 sets of complete data were received. Fifty- seven sets of data with scores on all four measures were 51 collected from the 90 students taking the Entry Profile in September 1973. The above data are summarized in Table 3-1. The representative qualities of the obtained scores were deemed acceptable. That is, comparison of the mean scores of those respondents who completed all four measures showed no significant differences from the mean scores of all subjects responding for each specific scale. Of the 11 faculty not responding to the survey, a variety of excuses was received. During the interview at which the forms were delivered, one responded that he was neither competent nor concerned about issues such as responsibility in medicine. Another explained that honest responses might be threatening to the school authorities and his own advancement. Still another claimed to be incapable of responding to the form of the items in the study measures to express his personal con- victions relevant to responsibility in medical education. No consistent reasons indicative of a response bias were seen in such rationalizations. The high cooperation of the class of 1972--71 of 85 turned in complete data sets (83%)--seemed to expose (a special pertinence of responsibility issues to students by the end of their first year of medical school. That Ifasponse rate was achieved in spite of the unfortunate clxoseness of the survey to exam time and the end of 52 mnma . . . . mswuoucm mnma . ummm mnma . ummm mnma . udmm mead . umwm was hm om muamwsum annaomz m mnma . cwumucm msma . ummm mnma .mmz mnma .mmz mead .mmz wmm an mm mucmnsum Hmonwmz mnmfl .Hfluma msma .aasn mums .masn mnma .aasn mph vm ms muasomm moH gem qu mass m s z dsouo musmsduumcH wcflocommmm mucousommmm ou cowumuumwcflaoé puma mo mmumo HIM mdnma 53 the school year. The class entering in 1973 took the four measures of this study as part of a battery which included more than 20 tests in all. The relatively low percentage of complete response sets--58 of 90 (64%)-- indicates a situation in which many subjects' reSponses could not be included due to the absence of one of the four scales needed as data points for this analysis. Comparison of elicited comments as well as equivalence of scale means indicated no response bias among the data sets accepted for analysis. Fifteen members of each class of students were randomly selected as a reliability sample and were readministered the MARS in April 1974. These 30 students were each offered $2.00 for their cooperation in retaking the MARS. All 30 responded to the personal request, and many indicated the money unnecessary. Of the 30 responses, 22 students had correctly completed the MARS in the original testing administration and allowed for computation of reliability correlations. Instruments MARS--Deve10pment A necessary process to be completed in the design of this research was the preparation of the Medical Attribution of Responsibility Scale (MARS). The develop- ment of that instrument followed the paradigm established by Shaw and Sulzer (1964). The incidents to be described 54 in the stories were drawn from several sources including: a critical incident survey of medical subgroups for examples of responsible behavior by student physicians (Loftus, 1970); the clerkship evaluations of medical students as performed by community physicians acting as faculty; solicitation of incidents from medical school faculty and students; observation of events within the Colleges of Medicine at Michigan State. The compiled inventory of incidents was then organized into stories which varied the levels of the outcome variables discussed in the Statement of the Problem--Quality, Intensity, and Association. The stories were then submitted to various medical personnel who rejected those stories whose material was not appropriate for first-year medical students, whose material contained rare or unrealistic situations, or whose material was internally inconsistent. The stories which remained demonstrated satisfactory realism and congruence with common experience in medical training. Each story contained one condition of Quality, Good or Bad, and one condition of Intensity, Mild or Severe. In order to reduce the total number of stories which par- ticipants would be asked to read, some stories were written to contain two actors with different degrees of Association with an identified outcome. Hence, some stories contained two conditions of the Association 55 variable: an Ambiguous association for one actor and the outcome and a Direct association for another actor and the same outcome. In all, 16 stories were selected which completely crossed the design variables as shown in Table 3-4. In addition to the stories selected for outcomes, eight more stories were selected in which the outcome was not specific. In these stories, the actor's behavior demonstrates different degrees of congruence with certain values or norms to which this medical school has claimed commitments. Some of these stories involve the compe- tition between responses as was mentioned in the dis- cussion on reSponsibility and evaluation in the intro- duction. The administered scale consisted of 24 situa- tional descriptions to which the subject is asked to reSpond by answering 39 questions about the attribution of responsibility in those situations. The response scale runs from (1) not at all responsible to (10) com- pletely responsible. The scoring of the MARS yields sums for each category of outcome variation as shown in Table 3-4. It also provides sum scores for several other factors. Causal is defined by the sum of scores on items 1 to 29 inclusive in which a specific outcome is presented. Items 30-39 define the Normative score, reflecting situations in which a more general example 56 of a type of behavior is performed, and no specific outcome is provided. Items can also be sorted to pro- vide scores for Student a sum of all items where the actor is a medical student or 95235 in which the actor is a faculty or resident, nurse, or patient. MARS--Reliability and Construct Validity Following the paradigm of Shaw and Sulzer (1967) in their develOpment of previous measures of attribution of responsibility, the construct validity of the MARS can be assessed through an examination of the adequacy with which the test materials evoke the perception of relevant variables and their intended conditions. Such an examination was undertaken by presenting the MARS stories to a group of medical students and faculty who were asked to rate each of the outcome variables in each story. After reading a story, instead of responding with a simple attribution of responsibility, these validity sample reSpondents answered several questions. How intense is the outcome of this story, Mild or Severe? Is the quality of the outcome in this story Good or Bad? Is the actor Directly or Ambiguously associated with the outcome? Table 3-2 gives a com- parison of the intended manipulation of the variables and their perception by respondents. The validity of the MARS can also be inferred from the pattern of 57 Table 3-2 Perception of MARS Outcomes Item # Quality Intensity Association 1 Bad 76% Mild 87% Ambiguous 66% 2 Bad 76% Mild 87% Direct 54% 3 Good 100% Mild 73% Direct 98% 4 Bad 91% Severe 89% Direct 76% 5 Bad 91% Severe 89% Direct 75% 6 Bad 98% Mild 62% Ambiguous 62% 7 Bad 98% Mild 62% Ambiguous 53% 8 Bad 98% Mild 62% Direct 67% 9 Good 98% Severe 65% Direct* 80% 10 Good 98% Severe 65% Direct 100% 11 Bad 93% Severe 96% Direct 82% 12 Bad 93% Severe 96% Direct 76% 13 Good 89% Mild 80% Direct 69% 14 Good 89% Mild 80% Direct* 84% 15 Good 98% Mild 64% Direct 62% 16 Good 98% Mild 64% Direct 80% 17 Good 96% Mild 76% Ambiguous 65% 18 Good 96% Mild 76% Direct 84% 19 Bad 51% Mild 70% Direct 58% 20 Good 98% Severe 70% Direct 100% 21 Good 100% Severe 64% Direct 93% 22 Good 100% Severe 64% Direct* 78% 23 Good 100% Mild 76% Direct 78% 24 Good 100% Mild 76% Direct 80% 25 Bad 98% Severe 98% Direct 80% 26 Bad 93% Mild 82% Direct * 89% 27 Bad 93% Mild 82% Ambiguous 78% 28 Bad 100% Severe 87% Ambiguous 71% 29 Bad 100% Severe 87% Direct 93% 30-39 Normative Note.--Causal attributions are made in items 1-29; tive attributions are made in items 30-39; Attri- butions to Students are made in items 1, lation. 9: 11: 13, 15, 17, 19, 20, 21, 23, 25, 26 Norma" 3: I 287 4: 6: 7. Attributions to Other medical personnel are made in items 2, 29. 5! 8: 10, 12, 14, 16, 18, 22, 24, * For these items, a majority of respondents designated the condition other than the intended manipu- 27, 58 results obtained and the relationships it shows among the variables of the research study. The reliability of the MARS can be estimated by computing the test-retest correlations between scores of subjects who have taken the test on two separate occasions. The whole class of medical students enter- ing in 1972 was administered the MARS in May 1973. A randomly selected group of 15 students was readministered the same measure in April 1974, 11 months later. Of the 13 students who took the MARS on both occasions, the average test-retest correlation was 0.69. For the eight members of the class of 1973 who took the test in September 1973 and again in April 1974, six months apart, the average test-retest correlation was 0.76. The agreement between intended manipulation of the variables and the perceptions of the respondents in the validity sample, and the reliability scores reported above, were accepted as indicative that this form of the MARS was adequate for an exploration of the questions identified in Chapters I and II of this paper. Further, the obtained results on construct validity suggest that the variable of degree of Association is more susceptible to individual differences than are the variables of Quality or Intensity of outcome. It was also recalled from the previous discussion of other research that the degree of Association was the most perceptually 59 sophisticated and develOpmentally difficult judgment to make. These issues will be recalled in the discussion of results. Another output of the validity study which was of interest was the observation that many respondents indicated that the use of the term Severe to describe Good outcomes was dissonant. A limit to the adequacy of the study of validity also emerged in debriefing anecdotes in which some respondents indicated that in that form of the measure the specific outcome was not always sufficiently clear. (A copy of the MARS instru- ment as validity questionnaire is included in Appendix C.) Interpersonal Check List The Interpersonal Check List (ICL) devised by LaForge and Suczek (1955) is a self-administered adjec- tive check list on which the respondent indicates which items he/she feels accurately describe characteristics for a given target person. In this study respondents were asked to describe themselves. Summary scores of Dom and Lov are assumed to express an ICL profile in terms of two underlying orthogonal dimensions, as was discussed in Chapter II. Computation of Dom and Lov is based upon sum scores for the 16 subscales. Those subscales are described below in terms of words which describe the lowest and highest end of each scale: Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale m C) 22 3 t‘ 3‘ Q Subscale scores can range from 0 - 20. 60 Able to give orders . . . . . Dictatorial Self-respecting . . Egotistical and Conceited Able to take care of Self . . . . Cold and Unfeeling . Cruel and Unkind Can be strict if necessary. . . Can be frank and honest. . . . Hard-hearted Can complain if necessary . . Rebels against everything Able to doubt others . . . Distrusts every- body Able to criticize self . . . Alwasy ashamed of self Can be obedient . . . . . . . Spineless Grateful . . . . . . . . Clinging vine Appreciative. . . . . Will believe anyone Cooperative . . . . . Agrees with everyone Friendly . . . . . . . . Loves everyone Considerate . . . Tries to comfort everyone Helpful . . . . Spoils people with kindness Well thought of . . . . Expects everyone to admire him Test score reliabilities are reported as ranging between 0.64 and 0.77 (Lange, 1970; LaForge, 1973). The validity of the ICL has been demonstrated through the relationships among ICL scores and MMPI scales as well as between ICL scores and various situational behaviors. 61 Attitude Toward Leadership Scale The Attitude Toward Leadership scale (ATL) is an instrument developed by Dr. Henry Clay Smith of the Psychology Department at Michigan State University. It is a 32-item forced choice inventory which requires the respondent to choose which of the two identified behaviors is more desirable in a good leader. The descriptions included in the scale are derived from Fleishman's typology of supervisory behaviors. The ATL form can be used either for self-report or to evaluate another leader. Research evidence suggests that higher scores on two defined subscales are associated with more effec- tive leadership. The 32 items are broken into two subscales. The first 16 items define a respondent's position on a scale of Consideration. Consideration refers to a dimension including the priority assigned to personal needs of workers as opposed to the priority assigned to task demands. The scale is scored by summing the number of items in which the choice emphasizing the personal needs is selected by the respondent. The second 16 items define a respondent's position on a scale labelled Responsibility. Responsibility refers to the degree of differentiation made between the roles of leader and worker. The scale is scored by summing the number of items in which the respondent selects the item stressing the role of leader. 62 Phrases describing a leader are given below in terms of the two constructs Consideration and Responsi- bility and their two poles: Low Consideration A leader who treats his workers without considering their feelings. A leader who refuses to explain his actions. A leader who acts without consulting his workers first. High Consideration A leader who puts suggestions from workers into action. A leader who is willing to make changes. A leader who makes workers feel at ease while talking to him. Low Responsibility A leader who lets students do their work in any way they think best. A leader who does not criticize poor work. A leader who does not emphasize quantity of work. High Responsibility A leader who insists upon quality. A leader who decides in detail what shall be done and how. A leader who spends his time in planning the work. The two scales of Consideration and Responsibility have been shown to have internal consistencies above 0.80 and a slight but negative correlation (Smith, 1968) r = -0.30. For the sample of this study, the correlation between the two scales was observed to be r = -0.36. 63 International Opinion Survey Based upon Rotter's social learning theory model, and derived from his original Locus of Control Scale, the International Opinion Survey attempts to improve the measurement of a person's belief in external versus internal control, i.e. whether fate, luck, or external factors determine success or failure (an external focus) or whether the capabilities of the individual are the primary determinants of success or failure (an internal focus). Unlike the original Locus of Control scale developed by Rotter, the IOS form breaks down the Locus of Control variablevinto six content-related categories which reflect the loadings identified in several factor analytic studies of the original scale forms. The 108 also includes a seventh scale which is derived from another of Rotter's earlier tests and designed to measure a person's interpersonal trust, defined as the degree to which a person believes that his relationships with others have predictability and consistency that allow him to share responsibility and control of situations with others. The seven subscales of the IDS are characterized below: 1. General luck or fate, e.g. many of the unhappy things in people's lives are partly due to bad luck. 64 2. Politics, e.g. one of the major reasons why we have wars is because people don't take enough interest in politics. 3. Respect, e.g. no matter how hard you try, some people just don't like you. 4. Academics, e.g. many times exam questions tend to be so unrelated to course work that studying is really useless. 5. Leadership success, e.g. capable people who fail to become leaders have not taken advantage of their opportunities. 6. Miscellaneous, e.g. statements which could be included in two or more of the above categories. 7. Trust, e.g. most people can be counted on to do what they say they will do. The 108 consists of 59 statements which the respondent can answer Agree, Disagree, or Can't Decide. The scoring for the various subscales is indicated on the following page, Table 3.3. Test-retest reliabilities for the original 23-item forced choice format of the I.E. or Locus of Control scale ranged from 0.49 to 0.83 after a two-month time lapse. Discriminant validity in terms of low correlations with such variables as intelligence, social desirability, and political affiliation was established through several 65 Table 3-3 Scoring Key for the International Opinion Survey Subscales Luck/ Miscel- Fate laneous Leader- POllthS Academic ship Trust Respect * * * 14 15* 17 10* 23* 24 25 27 12* 33 34 35* 37 38 39 16 43: 44 45 47 48 49 20 53 54 55 57 58 59 I'I'I-l' I: Note.--All entries are item numbers. * These items are revised scored : l, 2, 3 as they appear on the answer sheet should be scored 3, 2, l. 66 studies (Rotter, 1966). Predictive validity for the Locus of Control scale in a forced choice format has been good across a wide range of experimental contexts. That is, populations theoretically expected to be higher or lower on scale scores have been demonstrated to achieve those scores. The Agree-Disagree format of the International Opinion Survey (108) has been shown to be an adequate measure of the Locus of Control construct through its intercorrelations with the various Locus of Control scales. With the forced choice format of Locus of Con- trol, the 108 showed correlations of 0.53 to 0.79 after a six-week time lapse. This is within the same test range as the test-retest reliability shown by the forced choice form itself. The predictive validity of the 108 has also been established by demonstrating that the popu- lations score in the expected directions. Design of the Study This study is comprised of sections which will be subjected to separate statistical analyses. In character, the study may be said to be replicative, exploratory, descriptive, and correlative. The effects of outcome variables are expected to replicate the results reported by previous research. The extension of those results to the context of medical education and the develOpment of a measure of attribution of 67 responsibility appropriate to the field of medicine is an exploratory venture. It represents a logical extension of previous research efforts but needs to elicit verification of the adequacy of its application to a new field. The real and practical implications are involved in the description of the elements of the behavior which is defined as the attribution of respon- sibility. Medical education is an appropriate instance in which such a behavior has pragmatic importance. The basis for an empirical description is found in cor- relations established among the various measures under study. In this study the effort is to verify what is known about the attribution of responsibility; to vali- date those effects in medical judgments; to develop and apply measures appropriate to further study of attribution of responsibility in medicine; and to examine relations among attribution of responsibility and several per- sonality measures including two prepotent dimensions of interpersonal behavior which define a nomologic net. A visual presentation of the examination of out- come variables, Locus of Control, and Academic Level is made in Table 3-4. That table also shows which items on the MARS are associated with different conditions of outcome variables. It also includes the categories of I03 Locus of Control to be examined and the contrast between Faculty and Student or Academic Level. 68 vm mm mm ma mm b mm ma mm m ma Hm ma mm NH v m mm on ma ma Ha m H m m oa «a m moosmflhad homuwo moosmwnad uomufio moosmwhad nomuflo moosmflnad uomnwo mum>mm paw: mum>mm UHHZ com 8006 mcowuwoaoo magmaum> ou omcmwmms memuH mmmz sum magma 69 Statement of the Hypotheses Hypothesis 1: Attribution scores are equal for Good and Bad story outcomes; there is no Quality effect. (predicted direction Bad > Good) Hypothesis 2: Attribution scores are equal for Mild and Severe story outcomes: there is no Intensity effect. (predicted direction Severe > Mild) Hypothesis 3: Attribution scores for stories with Direct associ- ation between actor and outcome are equal to scores for stories with Ambiguous association between actor and outcome; there is no effect for Association. (predicted direction Direct > Ambiguous) Hypothesis 4: Attribution scores are equal across all conditions, or differ only by functions assignable to a design variable; there are no interactions. (predicted- interactions) Hypothesis 5: Attribution scores for Causal and Normative items are equal. (predicted Normative > Causal) Hypothesis 6: The mean scores attributed to Student actors are equal to the mean scores attributed to actors from Other roles, i.e. faculty, residents, nurses, patients. (predicted Other > Student) 70 Hypothesis 7: The Academic Level variable defined by Faculty and Medical Students groupings shows no difference between group means. (predicted Faculty > Students) Hypothesis 8: Attribution scores are equal for respondents grouped on the 108 into Internal, Middle and External on the Locus of Control variable. (predicted Internals > Middles > Externals) Hypothesis 9: There are no correlations among the scores on the MARS, ATL, ICL, AND 105; no regression coefficients will emerge to define an equation. (predicted Dom and Responsibility, Lov and Consideration, a regression equation will be defined) Analysis of the Data Analysis of the data proceeds through several steps. The first step deals with the effects of out- come variables on the attribution of responsibility as measured on the MARS. Quality, Good-Bad, Intensity, Mild-Severe, and degree of Association Direct-Ambiguous are each examined through Analysis of Variance as com- puted on the design presented in Table 3-4. Also tested in that design is the contribution to the variance accounted for by the Locus of Control measured by the 108. A separate analysis will allow for a test of the Academic Level variable. Separate ANOVAs will also be computed to examine the Causal-Normative compar- ison, and the attribution to Student-Other Roles. 71 Later steps will attempt to describe the relation- ships among scores on the other measures of personality function. In specific, a multiple regression analysis will attempt to correlate each respondent's scores in such a way as to provide an equation which can be used to predict the attribution of reSponsibility. That equation will include scores derived from the MARS, IOS, ICL, and ATL. Analyses will be performed at the computer laboratory of Michigan State University on the CDC 6500 using the Bastat and Finn programs. Summary This chapter presented the details of the study regarding sample, instruments, design analyses, and hypotheses. The sample is described as faculty and students from the College of Human Medicine at Michigan State University. They were administered several measures as part of a project authorized by the College. The instruments they took during 1973 and 1974 included the Interpersonal Check List (ICL), The Attitude Toward Leadership scale (ATL), a new form of the Locus of Con- trol measure called the International Opinion Survey (108), and an instrument whose development is part of this study, the Medical Attribution of Responsibility Scale (MARS). 72 The study is designed and described as repli- cating earlier research findings, extending them to the context of medicine, and developing and validating a new instrument to further explore the attribution of responsibility. Correlations are sought with other personality measures including the ICL, ATL on which a predictive effort will be based. Hypotheses are enumerated in the null form for test by Analysis of Variance and multiple regression analysis. CHAPTER IV RESULTS Effects of Story Variables The Medical Attribution of Responsibility Scale (MARS) is a measure which describes common events occurring within the context of medical education and asks the respondent to assign a rating of reSponsibility to actors in the story presented. There are 39 items which request an attribution on a scale from 1-10, with 1 being identified as not at all responsible and 10 being designated completely or exceptionally reSponsible. These attribution scores can be summed across different controlled levels of outcome variables. The outcome variables examined in this study included Quality, Intensity, and Association. There are two types of stories included in the MARS. One defines a situation in which the respondent is asked to make a judgment of Causal ascription--how responsible is this particular actor for this specific outcome. The second type of story asks the reSpondent to make a Normative judgment of responsibility--how 73 74 responsible is this kind of action or this level of performance. A summary score is computed for each of these types of stories. Each story includes several persons, and the agent of the action may be seen to be either a medical Student or some chg£_medical personnel such as a faculty member, resident, nurse, or patient, although most other actors are faculty members. Two scores can be computed which reflect these categories of Student or 92225. These scores reflect attribution to that academic level or 5212 of the actor and thus allow comparison of the average attribution to the different role categories. The results of comparisons of these forms will now be presented in the form of statistical tests of the null hypothesis. Analyses of variance were performed using the Finn program on the Michigan State University CDC 6500 computer. The design for the first analysis is given in Table 4-1 with the results presented in Hypothesis 1: Attribution scores are equal for Good and Bad story outcomes; there is no Quality effect. (predicted Bad > Good) Results: The hypothesis is rejected. 75 ~m.v nm.n oo.m mam.v mnm.m mae.h mav.m mvm.m new: undue m~.« mv.h mm.v om.v mo.m on.» hv.m Hm.w c802 macho h u z oo.¢ va.m mm.v mm.m m~.m ~o.n mm.» mm.m Huauouxm auanomm Hm I z m~.v ov.n no.m om.v Hm.m av.n n~.m mv.o wanna: w n z mm.v no.5 oo.m mm.v m~.m mm.m ha.m va.m HmcuoucH wm.m mm.h mo.m mn.v mm.m mm.s om.m mm.o new: moouu am I z mH.m mm.» ma.m mm.v ~o.w mn.h mm.m hm.w Hmcuouxm em a z ucopsum ~v.m mm.h Ho.m mw.v vm.m mv.h mm.m Hm.w manna: «N I z mm.m 5N.h No.m hm.v mm.m Hw.> ma.m cm.w HmcuousH moosoanfid uoouwo msosmflnfid uoouflo moosmwhs< uomuwo moosmwnsd uoouwo ouo>om paw: muo>mm paw: acuucoo Ho>oq can @000 no msooq oHEonuom moanmwu8> snoum mmcz J. Houusoo no bacon use .Ho>oq uwsocmod .moandwuo> meoouso up xuwawnwmcommmm mo coausnwuuud Hlv OHQMB How mmuoom goo: 76 Table 4-2 Results of the ANOVA of Outcome, Academic Level, and Locus of Control Variables Degree Sources of Variance of Mean Sq. F p < Freedom Academic Level , (Faculty vs. Student) (AL) 1 8.37 2.07 Locus of Control (Internal, Middle, External) (LC) 1 12.96 3.21 .04 Academic Level with Locus of Control (ALxLC) 1 .75 .81 Respondents within interaction of Academic Level and Locus of Control (R: ALxLC) 158 4.04 Quality (Good vs. Bad) (0) 1 141.07 82.67 .0001 Intensity (Mild vs. Severe) (I) 1 426.04 452.92 .0001 Association (Ambiguous vs. Direct) (Ass) 1 468.49 291.01 .0001 Quality X Intensity (QXI) l 54.59 56.60 .0001 Quality x Association (QxAss) 1 10.27 6.21 .0138 Intensity x Association (IxAss) 1 180.54 129.38 .0001 (QxIxAss) 1 101.82 59.68 .0001 ALxQ 1 6.83 4.00 .05 ALxI 1 8.11 8.62 .004 ALxAss 1 2.61 1.62 LCxQ 1 1.09 .64 LCxI 1 .89 .94 LCxAss 1 .32 .20 ALxQxI 1 6.08 6.31 .01 ALxQxAss l 14.03 8.48 .004 ALxIxAss l 1.14 .83 LCxQxI 1 3.03 3.14 .04 LCxQxAss l 1.21 .73 LCxIxAss 1 .49 .35 ALxQxIxAss 1 3.38 1.98 LCxQxIxAss 1 3.23 1.89 ALxLCxQ l 1.38 .81 ALxLCxI l .69 .73 ALxLCxAss l 2.38 1.48 ALxLCxQxI 1 .72 .74 ALxLCxQxAss 1 3.60 2.18 ALxLCxIxAss 1 .01 .01 ALxLCxIxQxAss 1 .14 .08 Quality x Respondents: within ALxLC QxR: ALxLC 158 1.71 IxR: ALxLC 158 .94 AssxR: ALxLC 158 1.61 QxIxR: ALxLC 158 .96 QxAssxR: ALxLC 158 1.65 IxAssxR: ALxLC 158 1.40 QxIxAssxR: ALxLC 158 1.71 t This F score was recomputed on revised format by FINN Program. 77 The grand mean score for stories with a Good outcome was 6.34 on a scale of 10. The grand mean score for stories with a Bad outcome was 5.58. Figure 4-1 shows that stories with a Good outcome resulted in greater attribution of responsibility scores in three of the four design conditions. In the Analysis of Variance (ANOVA) which was computed to test the sta- tistical significance of this Quality of outcome effect, the obtained result was an F statistic of 82.67 with 1 and 158 degrees of freedom; significant beyond the 0.0001 level. Hypothesis 2: Attribution scores are equal for Mild and Severe story outcomes; there is no Intensity effect. (predicted Severe > Mild) Results: The hypothesis is rejected. Stories with a Severe outcome resulted in a grand mean of 6.47 on a scale from 1 to 10 indicating the amount of responsibility attributed. Mild outcomes resulted in a grand mean of 5.44. Figure 4-2 shows that stories with Severe outcomes resulted in greater attri- bution of responsibility in three of the four design conditions. The Intensity variable was observed to have a significant effect demonstrated in the ANOVA performed on these data. An F value was computed of 452.92. Mean Attribution of Responsibility Bad, 78 Mild Mild Severe Severe Ambiguous Direct Ambiguous Direct Outcome Conditions Fig. 4-1. Effect of Qualit of outcome, Good- on Attribution of ResponsiEiIity Scores 79 Mean Attribution of Responsibility Scores Good Good Bad Bad Ambiguous Direct Ambiguous Direct Outcome Conditions Fig. 4-2. Effect of Intensity of Outcome, Severe-Mild, on Attribution of Responsibility Scores 80 With 1 and 158 degrees of freedom, that value is sig- nificant beyond the 0.0001 level. Hypothesis 3: Attribution scores for stories with Direct associ- ation between actor and outcome are equal to scores for stories with Ambiguous association between actor and outcome; there is no Association effect. (prediéted Direct > Ambiguous) Results: The hypothesis is rejected. Stories with a Direct association between actor and outcome were observed to have a mean attribution score of 6.58 on the 1-10 scale. Ambiguous association was seen to produce a mean score of 5.33. Figure 4-3 indicates that the Direct association led to greater attribution in three of the four design conditions. The significance of the effect for Association was assessed through the ANOVA performed on the study data. That analysis produced an F of 291.01, with degrees of freedom equal to 1 and 158; significant beyond the 0.0001 level. Hypothesis 4: Attribution of ReSponsibility scores are equal across all design conditions or differ only by functions assignable to a design variable; there are no interactions. (predicted interactions) Results: The hypothesis is rejected. 81 Scores Mean Attribution of Responsibility Good Good Bad Bad Mild Severe Mild Severe Outcome Conditions Fig. 4-3. Effect of Degree of Association, Direct--Ambiguous, on Attribution of Responsibility Scores 82 The analysis of variance performed on the story attribution scores obtained in this study revealed several significant interactions among story outcome variables. They are listed below in Table 4-3. Table 4-3 Significant Interactions Among Story Outcome Variables Variables F p < Quality X Intensity 56.60 0.0001 Quality X Association 6.21 0.01 Intensity X Association 129.38 0.0001 Quality X Intensity x Association 59.68 0.0001 (1) Quality X Intensity.--Severe outcomes were observed to result in greater attribution than Mild outcomes. This effect is stronger when the outcome is Bad than when it is Good. Stated in another way, this interaction can be said to show that while Good story outcomes generally result in higher attribution of responsibility scores than Bad outcomes, this effect is stronger under conditions of Mild outcomes than when the outcome was Severe. (2) Quality X Association.--Direct outcomes resulted in greater attribution than Ambiguous outcomes. This effect was seen to be slightly but significantly greater when the outcome was Good than when it was Bad. 83 Alternately, this can be restated in terms of the obser- vation that Good stories resulted in greater attribution than Bad outcome stories, and this difference is slightly greater under conditions of Direct association between actor and outcome. (3) Intensity X Association.--Direct outcomes received higher attribution scores than did Ambiguous outcomes, and this effect was greater when the outcome was Severe rather than Mild. Restated, Severe story outcomes result in even greater attribution scores than Mild in situations where the association between actor and outcome is Direct rather than Ambiguous. (4) Quality X Intensity X Association.--The three-way interaction of outcome variables was such that in stories with Good outcomes the Direct association condition resulted in a larger difference between Severe and Mild outcomes than did the Ambiguous association. In stories with Bad outcomes, the Direct association includes the Severe greater than Mild effect; but in conditions of Ambiguous association and Bad outcomes there is an inversion of the Severe-Mild relationship. This three-way interaction can be said to uniquely demonstrate that the condition of a story outcome which is Bad shows a compromise of the previously observed relation between Intensity and Association. 84 Hypothesis 5: Attribution score means for Causal and Normative are equal. (predicted Normative > Causal) Results: The hypothesis is rejected. The mean score for attribution in stories which involved Normative judgments was 6.22. The mean attri- bution score for Causal judgments was 5.93. The Analysis of Variance design and results which appear below pro- duced an F statistic of 14.24, with l and 152 degrees of freedom, which was significant at p.< 0.001. That finding indicates that in this study the Normative judg- ments led to attribution of reSponsibility scores that were slightly but significantly greater than the attri- bution scores of Causal judgments. Table 4-4 Design and Results of ANOVA Comparing Attribution of Responsibility in Causal Versus Normative Stories Causal Norm- ative Internal Middle External Internal Middle External Medical Students Faculty__ Source * F p _. < Judgment Context Causal vs Normative 14.24 0.001 85 Hypothesis 6: The mean scores attributed to Student actors are equal to the mean scores attributed to actors from Other roles, i.e. faculty, residents, nurses, patients: there is no Role effect. (predicted Other > Student) Results: The hypothesis was rejected. Attribution of responsibility to Students was observed to average 3.88 while attribution to actors in 922 E roles was found to average 8.75. This effect was found to be statistically significant and to be true for both faculty and medical student respondents. (A significant effect for Locus of Control was demonstrated in this ANOVA but will be discussed in a later section.) The design and results of the Analysis of Variance which was computed to examine the effects of Role are given in Table 4-5. That analysis produced a demonstration of a significant effect for differences in attribution to Student or Other. Role differences were associated with an F statistic of 3562.78, with l and 152 degrees of freedom; significant beyond the 0.0001 level. Summary of Results for Story Variables Each of the outcome variables designed into the MARS-~Quality of outcome Good-Bad, Intensity of outcome Severe-Mild, and degree of Association between actor and outcome Direct-Ambiguous--was found to contribute 86 Table 4-5 Design and Results of ANOVA Comparing Attribution of Responsibility to Student Versus Other Role Categories Student J Other Internal Middle External Internal Middle External Medical Students _j Faculty Sources df Mean F < Squares p Academic Level (A L) l .35 .32 - Locus of Control (LofC) 1 4.81 4.43 0.01 (A L) X (LofC) 1 .36 .33 - Respondents : (A L) X (LofC) 152 1.09 Role-Student vs Other 1 1883.40 3562.78 0.0001 (A L) X Role 1 .08 .15 - (LofC) X Role 1 1.45 2.74 - (A L) X (LofC) X Role 1 .22 .41 - Role X Respondents : (A L) X (LofC) 152 .53 87 significantly to the amount of attribution of responsi- bility, statistically demonstrated beyond the 0.0001 level. Each of the two-way interactions was also sig- nificant. Quality X Intensity and Association X Intensity interactions achieved levels of p ‘<.0001. The Quality X Intensity interaction showed a p.< .01 confidence level. The three-way interaction, Quality X Intensity X Associ- ation was significant at p < .0001. The Quality effect revealed that Good stories resulted in greater attribution scores than stories with Bad outcomes. The nature of the Intensity effect was that Severe outcomes resulted in greater attribution of responsibility than did Mild outcomes. The Association effect was such that Direct association between actor and outcome resulted in higher attribution scores than were seen in conditions of Ambiguous association between actor and outcome. The interactions generally reflected a different strength for the main effect under the two conditions of the interacting variable. For instance, The Good greater than Bad effect was larger in Mild conditions than Severe ones. The Good greater than Bad effect was slightly larger in Direct conditions compared to Ambiguous ones. The Severe over Mild effect was also larger in Direct conditions compared to Ambiguous ones. 88 The three-way interaction showed some compromise of the relation between Intensity and Association under con- ditions of Bad outcomes compared to Good outcomes. Responsibility attribution under the context of Normative judgments was seen to be significantly higher than attribution in Causal judgments: p < .001. Attri- bution to Student actors was observed to average much less than attribution to Qgggg actors, creating a sig- nificant effect for Role: p.< .0001. Respondent Characteristics The attribution of responsibility can be con- sidered to be a behavior on the part of the respondent to the MARS which reflects his/her perception of the events and relations portrayed by the story items. Such behavior may well reflect different characteristics of the respondent as they influence the perceptions or choices involved. Such a characteristic, for instance, could be the amount of previous experience with, or maturation of attitudes toward, the circumstances described in the different stories. In order to examine that possibility, this study included a comparison of the responses made by faculty respondents versus those made by medical student respondents. This faculty- student dimension was labelled Academic Level. Another factor which has been previously demon- strated to influence the pattern of attribution to 89 another person is a type of self-perception which has been identified as perceived Locus of Control. In this study, the relation between attribution of reSponsibility to another and opinions about one's own control over events was measured by the relation between scores on the MARS and the International Opinion Survey. Three groups were formed by scores on the 108, defined as being Internal, Middle, or External on the Locus of Control variable. Internals were defined as those more than one standard deviation above the mean, a score of 46 or greater. Middles ranged from 35-45, which represented the mean i one standard deviation. Externals were defined by a score of 34 or less which was more than one standard deviation below the mean. On the assumption that certain prepotent dimensions define a nomologic space for interpersonal characteristics, this study sought to examine the position of the respondents of this study within that space and to assess the potential for predicting attri- bution behaviors on the basis of those dimensions. The Dom and Lov subscales from the Interpersonal Check List (ICL) were used as a measure of the prepotent dimensions. Another set of orthogonal factors which was thought to have value in assessing attribution behavior was the Consideration and Responsibility subscales of the Attitude Toward Leadership scale (ATL). A sensitive 90 measure of association between these several measures is possible through a multiple regression analysis. Such an analysis also prepares for the prediction of attribution in the form of MARS scores by means of a multiple regression equation which indicates the rela- tive weighting of the various subscales. Hypothesis 7: The Academic Level of respondents, defined by Faculty and Medical Student groupings, shows no difference between group means. (predicted Faculty > Medical Students) Results: The null hypothesis was not rejected. No significant effect was observed for Academic Level. The average attribution score for Student respondents across all situations was 6.0, while the overall Faculty average was 5.95. This similarity resulted in the absence of any Academic Level effect in the ANOVA. Academic Level did, however, show sig- nificant interactions in the main ANOVA (Table 4-1). Those interactions were with the outcome variables of Quality, Good-Bad, and Intensity, Severe-Mild. Academic Level also interacted with the interactions between outcome variables: Quality X Intensity and Quality X Association. Those relations are identified in Table 4-6. 91 Table 4-6 Significant Interactions Between Academic Level of ReSpondents and Story Outcome Variables ‘Variables F p < Academic Level X Quality 4.00 0.05 Academic Level X Intensity 8.11 0.01 Academic Level X (Quality X Intensity) 6.08 0.01 Academic Level X (Quality X Association) 8.48 0.01 The nature of the interactions between Academic Level and the outcome variables involves the different strength of the outcome effects in the two groups. For instance, Students attributed more than Faculty in stories with a Bad outcome to explain the Academic Level X Quality interaction. The Academic Level X Intensity interaction was a function of Students attributing more than Faculty when the outcome was Severe. Academic Level x (Quality X Intensity) was a summation of these effects. The interaction of Academic Level X (Quality X Association) reflected a pattern such that when an outcome was Bad, Faculty attributed much less responsi- bility than Students if the Association was Ambiguous. Direct association in Bad outcomes resulted in similar attribution by Faculty and Medical Students. 92 Summagy of Academic Level Effects Overall, Faculty and Medical Student respondents did not differ in their mean scores on attribution of responsibility. They did differ, however, in the strength of the outcome variable effects they exhibited. Students showed smaller differences for Good over Bad outcomes than did Faculty. Students also showed larger differences for Severe over Mild outcomes. Finally, Students showed more attribution than Faculty for Bad Ambiguous outcomes. Hypothesis 8: Attribution score means are equal for respondents grouped on the IDS into Internal, Middle, and External on the Locus of Control variable. (predicted Internals > Middles > Externals) Results: The hypothesis was rejected. Differences in attribution of responsibility were observed among the categories of respondents clas— sified as Internal, Middle, and External on the IDS. The obtained averages were Internals 6.37, Middles 5.97, Externals 5.87. The analysis of variance identified this as a significant effect. On the design given in Table 4-1, the F of 3.23 with 2 and 158 degrees of freedom was significant at the p '<.05 level. (It was also 93 identified in the ANOVA on the design in Table 4-5; F = 4.43, df 1 s. 152, p < .01)."r A significant interaction between Locus of Control variable and the interaction Quality X Intensity was also observed; F = 3.14, df 2 & 158, p ‘<.05. The nature of the interaction appeared to involve the greater attribution of Externals in Bad, Mild outcomes. In that condition, alone, the average attribution score for Externals was higher than the Middles' while in other conditions the pattern held of Externals' averages being lowest, Middles higher, and Internals attributing the highest responsibility scores. Hypothesis 9: There are no correlations among the scores on the MARS, ATL, ICL, and 108 such that regression coefficients can be defined into a predictive equation. (prediction correlations will be seen between Dom and Responsibility of the ICL and ATL respectively as well as between Lov and Consider- ation of the same scales, a regression equation will be defined) Results: The hypothesis was not rejected. In order to explore the relationships among these several variables and address the issue of theoretical similarity among subscales, a multiple * The significant difference reported in the ANOVA was tested by Scheffé's contrast comparisons which indi- cated that the difference must be interpreted across all three means rather than between any two means. 94 regression analysis was computed. Table 4-7 presents the values computed for regression coefficients and defines the multiple correlations to be not significant. The F test of the null hypothesis which presumed no association between the dependent and independent variables in the regression analysis was not signifi- cant, and the null hypothesis could not be rejected. Table 4-7 Standardized Regression Coefficients for Predicting MARS Scores Dependent Variables Predictors MARS - Causal MARS - Normative IOS total 0.28 0.19 Dom 0.16 0.06 Lov 0.14 0.25 Responsibility 0.05 -0.10 Consideration 0.12 0.01 The computed multiple correlation for predicting MARS - Causal scores was 0.31 which yielded an F of 1.42 which was not significant. The multiple r for predicting MARS - Normative was 0.24, F = 1.16, also not significant. On the basis of a priori examination, certain of the subscales in this study were believed to represent different measurement approaches to similar constructs. As a consequence of this assumption, the correlations 95 between Dom on the ICL and Responsibility on the ATL, and between Lov on the ICL and Consideration on the ATL, were of special interest. The correlations obtained in this study did not achieve significance. The cor- relation between Dom and Responsibility was r = 0.13, and the correlation between Lov and Consideration was r = 0.10. The statistical manipulations of data which are associated with a multiple regression analysis and the correlations which it computes require a reasonable adherance to certain assumptions about the distribution of the data. The data of this study were subjected to examination, and the descriptions of the distributions are given in Table 4-8. The lack of power to predict MARS scores from the personality measures is most probably due, in this study, to the overwhelming pro- portion of the variance in MARS scores which is accounted for by the variables within the stories. A further caution in the interpretation of the observed correlations reflects that the respondents in this study report themselves to be much more loving and dominant than other populations. College males averaged Dom = 2.70, s.d. = 6.42, and for college females Dom = 0.44, s.d. = 7.84 while this study's respondents averaged Dom = 12.11, s.d. = 14.64. College males showed Lov = 0.69, s.d. = 7.36 while college females 96 mv.~ s~.on ma.m meum oo.ma coma ucmespmuumuflaflnsmcommmm mm.~ H4.on mm.~ Hm oa oo.mH co 4 suasomm nmnm mm.on omnm 4m.aa oo.ma comm unmasumuucoaumumUHmcou mm m mm.ou an m mo.~a oo.mH co m suasomm . . m4.~ mm.ou m~.ma mm.ma om.~m om.mmu usmezumuu.>oq Ho.m Nv.oa mm.v~ mm.va om.mm om.mvu muasomm 4m.m om.on no.4a Hm.HH om.~4 om.mmu unmeaumuu.soo m~.m mH.Hn mm.ma No.ma om.m4 om.mmu suasomm sm.m 4m. mm.m mm.ov oo.mm oo.m~ eoamoH no HOHuwGOU MO MDOOA mm.~ 4N.n sm.ma mm.moa oo.mma oo.me umruo HA.~ mm. mm.oa mm.mm oo.mm oo.H4 usmesum mm.~ so. sm.m ma.~m oo.Hm oo.mm m>flsmsuoz an.~ mm. ma.o~ mm.ana oo.m~m oc.m~a Hmmsmo sowumw>oa msHm> wsHm> memouusx mmmszoxm pumccmum cmmz Edfiflxmz ESEHGMZ magmaum> mmHQMHum> sowmmmummm mamfluasz Mom moaumwumum sowusnfluumflo mlv OHQMB 97 averaged Lov = 2.82, s.d. = 9.63. The respondents in this study averaged Lov = 15.22, s.d. = 19.66. The medical students and faculty in this study also selected more considerate behaviors as ideal for leaders X = 11.90 compared to college students X = 9.00. Summary of Respondent Char- acteristic Effects The Academic Level of the respondent, Faculty versus Medical Student, did not produce a significant effect on attribution of responsibility. Academic Level did interact with certain outcome variable effects such that compared to Faculty, Medical Students showed less increase of Good scores over Bad but more increase of severe scores over Mild. Students also attributed more in Bad, Ambiguous conditions. Locus of Control showed a significant effect such that Externals attri- buted less responsibility than did Middles who in turn attributed less than Internals. This effect was modified in Bad-Mild outcomes where Externals attri- buted more responsibility than Middles. No significant regression coefficients were derived from subscales on the IOS, ICL, or ATL for predicting MARS scores. CHAPTER V DISCUSSION AND CONCLUSIONS The research presented in this paper was designed to examine and clarify the way in which persons in the area of medical education attribute responsibility to other persons acting in the context of medicine. The first procedure of this investigation was the development of the Medical Attribution of Responsibility Scale (MARS) as an instrument for measuring attribution of responsibility within the medical context. The second procedure involved the use of the MARS to examine the effects of different variables upon responsibility attri— bution scores. Two major groups of variables were studied. Story variables were (1) the different conditions of outcome--Qua1ity, Intensity, and Association; (2) type of story--Causal or Normative: and (3) role of the person acting in the story. Respondent variables included Academic Leve1--Faculty or Medical Student; Locus of Control category--Internal, Middle, External; and, personality scale scores of Lov and Dom from the ICL and Consideration and Responsibility from the ATL. 98 99 The details of the development of the MARS were presented in Chapter III on Method. The results of the data analysis obtained by examining respondents' answers to the MARS were presented in Chapter IV on Results. In this chapter, discussion will provide a synthesis of the MARS instrument's character and potential. Discussion will also present and interpret the pattern of results obtained in this research and compare it with previous research. Finally, a critique of this study will be provided offering possible improvements and suggestions for future research. Part I The MARS Investigation of the attribution of responsi- bility has been carried out in several contexts. Shaw and Sulzer (1964) reported an early experiment which made an empirical test of the theories proposed by Heider (1958). In that research, Shaw and Sulzer utilized an instrument they developed which described stories about "common place events" in the lives of children or college students. Simply labelled the AR scale, that measure varied the outcome Quality, Intensity, and Levels of Association between actor and outcome. Other researchers have utilized the evaluative context of jury decisions in asking subjects 100 to make attributions of responsibility (Walster, Shaver, Phares). That research attempted to control the severity of outcome (Intensity) and degree of Associ- ation but commonly focused upon negative outcomes which followed from accidental happenings. In accord with the realization that the situational context of the attribution of responsibility influences the judgments made, it was decided that a medical form of AR scale would be necessary to investigate attribution of responsibility in medicine. Following the format used by Shaw and Sulzer, the MARS was developed as a series of stories which described events reasonable to occur in the context of medical training. In order to observe the fullest set of relations among variables, the MARS included all three of the variables shown to be significant by previous research. On the basis of a conceptualization of responsi- bility developed concommittantly with this research, another element was added to the MARS. This was the inclusion of stories which did not require simply an attribution based upon a specific outcome but rather demanded attribution of responsibility for behavior offered as typical of a norm. This represents an exploratory effort to investigate reSponsibility not only as a causal relationship but also as a value- directed relationship which defines certain behaviors as right, others wrong, and still others irrelevant. 101 The MARS represents a comprehensive measure of the known and expected components of the attribution of responsibility. As such, it appears to be unique to this point and offers a model for the development of other scales specific to other contexts of evaluation or judgment. It offers further interest as an instru- ment for comparing the responses of those within the role and context for which it is specific, i.e. medicine, with the responses made by other subjects who are not identified with that role. Significant differences are expected on the basis of previous research (Loftus, 1970), but their empirical character is unknown. Finally, the present MARS measure of the attribution of responsibility allows for the demonstration of the interactions among all the known variables which no previous research has done. The manipulation of the outcome variables for the MARS was pre-tested and checked for validity. These exercises demonstrated that the Good-Bad dimension was well defined by the consensus. Examples tended to be phrased in terms of the patient's improvement or deter- ioration of his condition. Others focused on the attainment or failure of the student's learning. The Intensity variable of Mild-Severe was also widely agreed upon. Mild outcomes ranged from wasted time and emotional distress to slight changes in patient's 102 disease condition. Severe outcomes were expressed in terms of prolonged hospitalization, omission of proper care, or even death. The dimension which showed the greatest variance in consensus was the degree of Associ- ation between the actor and outcome. The manipulations of this dimension were couched in terms of intention, foresight, and effort as well as ability. In general, these manipulations were successful in inducing the proper perceptions from respondents as judged both by the debriefing comments and the results of the study consistently supporting other research. Part II The Data on Attribution of Responsibility The following issues were demonstrated by the present research as contributing to the attribution of responsibility: The most important variable in deter- mining the amount of attribution was the academic Role of the actor: Medical Students were given much lower scores on attributed responsibility, X = 3.88 compared to Other medical personnel X = 8.75. The second most important factor appeared to be the degree of Association between the person and the outcome, with Direct associ- ation producing greater attribution scores than Ambiguous association. The Quality of the outcome demonstrated a significant effect such that in this study Good outcomes 103 resulted in greater attribution than Bad outcomes. Intensity of outcome also contributed significantly such that Severe outcomes resulted in higher attribution scores than Mild ones. It was also observed that attri- bution of responsibility made to Normative behaviors was higher than attribution made to Causal behaviors. Finally, the Locus of Control category of the respondent showed a significant effect such that Externals attributed least responsibility, Middles slightly more, and Internal respondents attributed the highest average amounts of responsibility. In this study, ICL and ATL scale scores were not shown to correlate significantly with the amount of responsibility attributed by individual reSpondents. In general, the above stated results are remarkably consistent with the predicted directional hypotheses. The coherence of these replications is well developed in the first chapters which document their presentation in previous research. A number of elements stand out as appropriate for further comment here. First, there is the directional effect of the Quality of outcome results such that in this study Good outcomes resulted in higher attribution of responsibility scores than did Bad outcomes. Second, the interaction between outcome severity and degree of association is here demonstrated to be consistent with the findings of Phares and Wilson 104 (1972) and lends further credence to their interpretation. Their report, however, dealt only with negative outcomes so that the extension of the Intensity X Association interaction represents a unique contribution of this study. Further, there has been no previous study which controlled all three factors of Quality, Intensity, and Association in order to demonstrate the three-way interaction among them which is reported here for the first time. In addition to the above successful replications and extensions, this study examined for the first time the relation between attribution for a specific outcome and normative attribution of responsibility. The sig- nificant effect which showed normative stories to result in greater attribution should be provocative of further examination and will perhaps lead to an elaboration of the relation between the functions of causal efficacy and comparison to standards as was discussed in the beginning of this paper. The failure to observe a significant main effect for the Academic Level variable is assumed to reflect the maturity of the respondents as well as a successful screening of MARS items for those appropriate to the level of first-year medical students. The failure to cobserve significant relations between subscales on the ICL and ATL appears to be due to the special distribution 105 of variance in this study sample which prevents an adequate test of the hypothesis. Future research may productively focus upon the elements identified as susceptible to individual differences in this study and relate the effects of different scores on the ATL and ICL to that data. Quality of Outcome: Good'vs.’Bad Previous research by Shaw and Sulzer indicated that the stories they used led to higher attribution scores in situations with bad or negative outcomes com- pared with good outcomes. They interpreted this as an apparent tendency on the part of most people to be more willing to give blame than credit. In the discussion of their results, they compare adults who appear to take circumstances into account when giving credit but not when placing blame, with children who seem to reduce blame when the negative outcome is provoked. However, the effect that Shaw and Sulzer described was not consistent over all the levels of association which they examined; and in particular, at the level of purposive commission where the actor was evaluated on an action and outcome which he intended, the negative or bad outcomes generally did not produce a significantly higher attribution than good outcomes. Likewise, in a different study (Garcia-Esteve & Shaw, 1968) the bad 106 greater than good effect was observed only in urban sub- jects while rural subjects attributed higher scores for good outcomes than for bad. The results seen in this study argue for a re- assessment of the function of Quality of outcome (good- bad) in terms of the contribution of the intention of the actor and of the context of judgment in general. The cognitive set of the respondent is clearly important in terms of what function he sees his judgment performing. In previous studies, the level of blame may be more sig- nificant since social action usually follows blame more closely than credit. Likewise, in the jury context, assignment of accountability and culpability are para- mount concerns. The setting and character of this study offers an interesting contrast. In the context of an educational evaluation, good and bad outcomes take on special significance. The good outcome is a signal of adequate performance and success in the training task. Bad outcomes on the other hand may signal either a simple need for further learn- ing, or if the consequences are severely negative may require a high degree of accountability in order to reduce the chances of reoccurrence. Such a pattern fits the data of this study rather well. Bad mild outcomes are given small attributed responsibility scores. Good outcomes are given higher attributions in proportion to 107 their importance and in proportion to the directness of their association with the actor. Severe Bad outcomes show very different scores as a function of whether they are clearly associated with the actor's behavior. If the actor is directly associated with a severe bad out- come, then high attribution is observed in keeping with the need to control such outcomes and prevent reoccur- rence. However, if a severely bad outcome is only ambiguously associated with the actor, then low attri- bution of responsibility is observed. The differential attribution to students versus other personnel supports the interpretation that it is the educational context of respondents' judgment which accounts for good out- comes getting higher average attribution than bad out- comes. Another possible explanation of the different Quality (Good—Bad) effect seen in this study may be due to the context of medicine rather than the context of education. It may be that the tendency proposed by Shaw and Sulzer for most people to blame more readily than give credit is somehow reversed in certain situ- ations which are defined as ones in which good is accomplished. Thus, subjects may find it easier to praise a doctor than blame him for mistakes. It has been observed that in certain high-risk tasks, negative results often bring less blame than they would in other contexts. 108 The Interaction Between Intensity and Association Contradictory results were reported on the increase in amount of attributed responsibility with the increase in severity of outcome until Phares and Wilson (1972) demonstrated the interaction of increasing severity with the degree of association between actor and outcome. They reported, however, that under conditions of Ambiguous structure they observed no increase in attri- bution with increase in severity. The present study replicates their findings for those stories which have negative outcomes. However, for the stories of this project which included good outcomes, increasing severity of outcome was seen to lead to increased attribution under both ambiguous and direct association. That three-way interaction was reported here for the first time. Part III Critique and Proposals The importance of the judgment context to the attribution of responsibility has been clearly demon- strated by the current research. The issues of the respondent's relation to the actions in the story also emerge as potentially significant. This information can be used to design future research so as to control and observe the effects of these variables. 109 The relatively overwhelming contribution of outcome variables makes the study of personality dif- ferences in the attribution of responsibility more dif- ficult. In one sense this is a practical blessing since we can expect that most persons having to make attri- butions of responsibility will agree on the basis of the evidence they are given rather than differ due to their own characteristics. The experience gained in this study suggests, however, that the most fruitful area for future investigations of personality dif- ferences may lie in the respondent's perception of the degree of association between actor and outcome. In developing and validating the MARS, it appeared that individual differences emerged most clearly when persons were asked to state whether the association between actor and outcome was direct or ambiguous. This also provides a point of integration between the attribution of responsibility and the interpersonal attribution of other characteristics such as intention, effort, and ability. This study also points the way toward future investigations of differences in attribution of respon- sibility for a Specific causal event versus more general normative behavior. Such research will be necessary in order to further define the relations among the several 110 uses of responsibility: as a personality trait, to describe causal efficacy, or to describe congruence with a standard. Among the studies which are indicated by the findings of this research should be one which administers the MARS to a group of respondents of similar academic and social characteristics with this medical group but which does not have the same association with the pro- fessional commitment of medicine. It would be valuable to find if the good greater than bad effect would be seen there. It would also be significant to find whether the assignment of sanctions paralleled the attribution of responsibility in both types of populations. The observed differences between causal and normative attribution should be further delineated, again in groups both practicing and receiving medical care. The area of greatest individual differences was previously indicated to lie in the perception of associ- ation between an actor and outcome. The MARS can easily be adapted for exploration of that area. It should also be used to examine the practical effects of such measured differences on actual performance in the clinical setting. An additional place for practical application would be the study of such evaluatory bodies as the Student Performance Committee in an effort to predict and thus improve the understanding of the decisions of such bodies. 111 Summary This research reported the development of an instrument for measuring attribution of responsibility in the context of medical education (MARS) and the sub- sequent use of that instrument to examine the contri- butions of outcome and respondent characteristics. Outcome association with the actor (direct or ambiguous), Quality of goodness or badness, and mild or severe Intensity were each shown to have significant effect. The status of the story actor showed strong effect, and the causal or normative character of the story was also significant. Respondent's Locus of Control (Internal or External) was shown to effect amount of responsibility he/she attributed. The situational context of the respondent's judgment has been identified as an important contributor to the attribution function producing differences which lead to further questions about the intentionality or accidental quality of the actor's behavior. Judgments about degree of association between actor and outcome are suggested as a fruitful area for investigation of further individual differences. APPENDICES APPENDIX A COMPOSITE PROFILE OF A ”RESPONSIBLE PERSON" WITH SYNTHESIS OF CORRELATED RESEARCH FINDINGS AND CATEGORIZATION OF BEHAVIORS APPENDIX A Table A-1 Components of Responsibility Identified by Various Research Teams Loftus Havighurst Gough, Harris, Homant, & Taba McCloskey et. al. Berkowitz & & Meehl Stone, Brown & Lands- berger Indepen- Self con- Strong dence fident Personal Nonauthor- security itarian person- ality Assurance Mature Requires Requires little little super- super- vision vision Reject Reject privilege privilege Initia- Initiative Poise Initiative tive Solves Resource- problems ful Seeks service Faces dif- ficulties Relia- Efficient bility or Fulfills Does his Gets things Capable dependa- tasks part done bility Carries thru Dependable Dependable Dependable Reliable 112 113 Table A-1 (Continued) Loftus Havighurst Gough, Harris, Homant, & Taba McCloskey et. a1. Berkowitz & & Meehl Stone, Brown & Lands- berger Relia- bility Punctual Punctual or dependa- Consistent bility Accepts Account- conse- able quences Trust- Can count Trustworthy worthy on Serious Square Honest shooter Orderly Con- Conven- formity tional Conform- Conforms to ing social norms Socia- Loyal to Sense of Loyal bility group obliga- tion to group Group High social centered desirabil- ity "Socially forth- coming" Thinks for good of others Helps depen- dent others Sociable 114 Table A-1 (Continued) Loftus Havighurst Gough, Harris, Homant, & Taba McCloskey et. a1. Berkowitz & & Meehl Stone, Brown & Lands- berger Socia- Res ected bility p Altruism Sense of justice Prepare Concern for con- for tribution broader to social society moral issues Construc- tive interest Rightness of world 115 Identification of Responsible Behaviors Four studies have contributed the majority of this descriptive material, and their contributions will be designated according to the following key: Havighurst and Taba (1949) = I; Gough, McClosky, and Meehl (1952) = II: Harris et a1. (1954, 1957, 1954a, 1954b, 1955, 1958) = III; and Brown and Landsberger (1960) = IV. According to these researchers: The responsible person has "a strong nonauthori- tarian personality" (III), with a "strong and unflagging sense of confidence in himself" (II). He considers his first duty is toward his own success (I). He requires little supervision (III), demonstrating personal inde- pendence (III) from both peers and adults (I), in carry- ing out his task (I) and in fulfilling his promises (I). He demonstrates initiative as "foresight" and "readiness to accept new tasks" (IV) or even seeking out opportuni- ties for service (I). He is willing to face difficulties in carrying out what is expected of him (I) and exhibits initiative in solving such difficulties (I). He is resourceful (III). Others can count on him (II) to carry through activities (III) and fulfill tasks expected of him (I). By always completing accepted jobs (I), he demonstrates dependability (II, III), reliability (IV), conscientiousness (IV), and trust- worthiness (II, IV). He is punctual, and demonstrates 116 this in his attendance (I). He demonstrates almost excessive emphasis on carrying his own share of burdens and duties (II). Further, he shows a ready willingness to accept the consequences of his behavior (II). He is orderly (III). He has a sense of rightness of the larger social world (II). He conforms to social norms (behavior) (III), and there is conformity between his attitudes and societal expectations (III). He has a sense of obligation to the group (II), and is socially oriented or group centered (III). He demonstrates sociability in terms of good relations with others (IV) and helpfulness to others (III, IV). He participates well (III). He is mature (III), and has constructive interests (III). He has a high but somewhat rigid set of self-demands (II) and highly developed standards (I, II) which he applies under a variety of circumstances (I). He is a straight shooter (II) with a strong sense of justice (II). He shows deep concern over the broader ethical and moral problems (II), and rejects the light, trivial, or dangerous (II). He also rejects privilege or favoritism (II) and disapproves of leniency toward athletes or talented or forgetful people (I). Although work outside school is taken somewhat more seriously than school work or activities, duties are taken seriously at school, home, and employment (I). 117 The responsible person demonstrates the qualities listed above in all situations with both supervisors and peers (I). APPENDIX B STUDY INSTRUMENTS MICHIGAN STATE UNIVERSITY 119 COLLEGE OF HUMAN MEDICINE - OFFICE OF THE DEAN EAST LANSING ' MICHIGAN ° 48824 May 24, 1973 MEMORANDUM TO: Year I Students FROM: James L. Conklin, Ph.D., Associate Dean for Student Affairs RE: Student Participation in a Study of Professional Responsibility Enclosed are three forms which we would appreciate your come pleting as part of a study of attitudes and judgments related to professional responsibility in student physicians. Medical schools, including MSU, focus on professional responsibility as an attribute to be developed by students. However, judg- ments of this attribute are largely personally and unsystemati- cally arrived at. We are asking you to help us clarify the process of making such judgments by contributing your time to complete the enclosed forms. The on-going project of which this is a part is intended to contribute to both the College's developing evaluation program and future admissions consider- ations. Each form has a separately identified answer sheet and instruc- tions for completion. It should not take you longer than 45 minutes to complete the materials. Do not identify yourself on the answer sheets; they have been precoded with your CHM identification number which is only interpretable by my office. In no way will you be personally identified in the course of this study. The forms and completed answer sheets should be returned to the Office of Student Affairs by noon, Tuesday, May 29. Thank you for your cooperation. MICHIGAN STATE UNIVERSITY 120 (;()|.l.l".(.'l'l OF HUMAN MEDICINE ° OFFICE OF THE DEAN EAST LANSING ' MICHIGAN ' 48824 May 29, 1973 To: First Year Student # From: James L. Conklin, Ph.D., Associate Dean for Student Affairs Subject: Student Participation in Study on Professional Responsibility We have not received the completed materials sent to you last Thursday with a requested return date of noon today. I recognize the demanding nature of your present schedule, but hope that you can take the time (45 minutes or less) to complete the forms. Our concern over the completion of these materials is related to the need for planning and program develOpment this summer in the area of professional responsibility. Your cooperation in returning these forms as early as possible, prior to Friday June 1, is appreciated. Should you have misplaced the forms, or received an incomplete set, Mrs. Beth Buchner of my office can assist you. MICHIGAN STATE UNIVERSITY 121 COLLEGE OF HUMAN MEDICINE ' OFFICE OF STUDENT AFFAIRS EAST LANSING ' MICHIGAN ° 48824 August 1973 MEMORANDUM TO: FROM: James L. Conklin, Ph.D., Associate Dean for Admissions and Student Affairs SUBJECT: Student Participation in Study on Professional Responsibility We did not receive the completed responses to the attached materials when they were sent to you last May. I recognize the demanding nature of your schedule at that time, but hope that you will now find occasion to complete these forms. Your cooperation in returning the forms as early as possible is appreciated. JLC/bjs 122 ... ' ATTRIBUTION 0F RESPONSIBILITY INSTRUCTIONS: On the following pages are brief descriptions of situations involving medical students with others. For each question following a description. your task is to indicate how responsible you feel were the actions of an individual re resented in the story. Judgments of responsibility are to be made on a 0 point scale moving from "not at all responsible” (l) to “completely responsible" (10). On the Fur le answer sheet. for each question darken the nunber corres- pondin 0 your choice of degree of responsibility. Some descriptions are fo lowed by two questions. each related to a different individual. In these cases. there is‘ no need for your Judgments of responsibility to equal a sum of lo. That Ts'. you may indicate that both individuals were ”completely responsible" or that both were "not at all responsible" or any other combination. . You may indicate on the back of the page any cements you wish to make - about the descriptions or questions. Your thoughts about ”responsibility”. . in addition to t e numerical Judgments. will be helpful in ultimately de- fining its measurement and formal inclusion in the curriculum. As you read through these situations some of them may strike u as partic- ularly meaningful learning experiences. After you have finis ed All of the ' descriptions select two which you feel represent the most meeningf'fl'experiences, and two which you fe'e'T—represent the least meaningful experiences. List them in tTI'E-spaces below. ' " MOST MEANINGFUL ‘ LEAST MEANINGFUL 123 Record your Judgment by question number on the separate answer sheet. Situation A: Situation 8: Philip 8.. while serving his duty night at the hospital. spent the evening in the call room reading material relevant to some problems which his patients had. He did not get any phone calls. and so thought that there were no new'admissions or other clinical experiences which he ought to pursue. If he had attempted to call the resident. he would have found that the house staff was in fact very busy that night. and was looking for him although his resident failed to phone the call room. (1) How responsible is Philip for missing the clinical experience and not doing some share of the work? not at all completely responsible responsible 123456789") (2) How responsible is the resident for Philip missing the clini- cal experience and not doing some share of the work? not at all completely responsible responsib e 12345678910 Kevin c. did the acknissions work up of a ediatrics case which involved a very frightened and lonely chi d. Kevin returned several times to sit and talk with the child. and comfort him during his hospital stay. During these visits. the child became noticeably calmer and looked excited whenever Kevin came into the room. ~ . (3) How responsible is Kevin for the child feeling better? not at all ‘ cmpletely responsible responsible l2345678910 124 Record your Judgnent by question number on the separate answer sheet. Situation c: Fred H. prescribes an expensive medication for a patient's ill- ness. without checking on the patient' 5 financial condition or telling him how much the medication will cost. The patient can- not afford the drugs. but is ashamed to mention it to Fred. Hithout the medication. his illness gets worse. (4) How responsible is Fred for the patient getting worse? not at all completely responsible responsible 12345678910 (5) How responsible is the patient for his condition getting worse? not at all ceanplet responsible responsible 12345678910 Situation 0: A faculty member agreed with 061 to give a scheduled lecture on a particular topic because of recent attention to that topic in the news. and new evidence of its importance in clinical medicine. He spent several hours preparing his talk. At the scheduled time however. no students showed up for the lecture. Some did not come because they were busy with other things on their schedule. Others . did not come because they were not interested in that topic. (6) Of those who did not come due to conflicts in schedule. how responsible were those students for the faculty mmber' s vested time? not at all ~ . . completel ' responsible responsi bIe 12345678910 125 Record your judgment by question number on the separate answer sheet. 51 tuati on E: (7) Of those students who did not come because they were not interested in that topic. how responsible were those stu- dents for the faculty member's wasted time? not at all completely responsible responsible 12345678910 (8) How responsible was 061 for the faculty member's wasted time? not at all cmpl etel responsible responsib e 12345678910 Mike L. did a very thorough work up on a newly adnitted patient assigned to him by Dr. 0. In addition to recording complete information. Mike identified several specific problems and planned :fipmpriate treatment which was carried out. In reviewing the art later. Dr. 0. was able. on the basis of the completeness of the chart. to recognize another problem. which although rare and swewhat esoteric. is life threatening. Dr. 0. sees that the ' problem is treated. and conlnends Mike for the completeness of the records in the chart. . (9) How responsible is Mike for the recognition and treatment of the additional problem? - not at all completel responsible responsible 12345678910 (10) How responsible is Dr. 0. for the recognition and treatment of the additional problem? not at all - completely .‘ responsible responsible 12345678910 _._..-_...«-._.--... - a 126 Record your Judgment by question nunber on the separate answer sheet. Situation F: Situation 8: In preparing the chart notes for a patient. Bernie F. wrote the orders in an illegible manner such that they could not be read. In trying to decipher the orders. a nurse made a mistake in the translation. administered the wrong drug and the patient died. (ll) l-iow responsible is Bernie for the patient's death? not at all _ completel responsible . responsib e 12345678910 (12) How responsible is the nurse? not at all completel responsible - responsib e 12345678910 -- ------------------------.---- --- ------ ---- ---------.- --- - .--- - -a Tom P. was assigneda newly admitted patient to work up Just after five o'clock. as he was preparing to go home. He considered doing a quick check to cover the night. and leaving the complete work up til morning. The resident told him he should'stay and do the com- plete work up now. so that the chart will be readyfor morning " rounds: which Tom did. , - (13) How responsible is Tom for the chart being ready for morning rounds? . not at all canpletel responsible responsib e 12345678910 (14) How responsible is the resident for the chart being ready for morning rounds? not at all completely responsible responsib e 12345678910 127 Record your Judgment by question number on the separate answer sheet. Situation H: Hhile going on rounds with the staff Dr..Robert M. asked. out of curios ty. about the connection between a specific symptom x and the treatment plan for a patient they had Just seen. In explain- ing his answer. Dr. 2 realized that he had not taken that connec- tion into account. and changed the patient's therapy. (15) How responsible is Robert for the patient's improvement on the new therapy? not at all * completely responsible responsible 1 2 3 4 5 6 7 8 9 10 (16) How responsible is Dr. Z for the patient's improvement on the new therapy? not at all completely responsible responsible 1 2 ‘3 4 5 6 7 8 9 10 Situation I: Brenda R. and Stephen c. were discussing the success of their class . in _. and Brenda was quite clear in expressing her disappoint- menf {Eat the class had failed to cover two of the assigned objec- tives. Without their knowledge. their conversation was overheard by a faculty member. Dr. x. It happened that Dr. X was scheduled to teach the next class in their program. and althsugh he had not origi» 'nelly planned t3.he saw to it that those two objectives were now covered in his class. (17) How responsible is Brenda for the obJectives being covered? - not at all , completely responsible ' responsib e I 2 3 4 5 6 7 8 9 10 128 Record your Judgnent by question nunber on the separate answer sheet. (18) How responsible is Dr. X for the objectives being covered? not at all ’ completely responsible responsible l 2 3 4 5 6 7 8 9 10 Situation J: while on duty in the ER. Howard D. saw a patient with fever. cough. dyspnea, tiredness and dizzyness. These symptoms are almost identical to several previous cases diagnosed as flu which he had seen that day. He incorrectly diagnosed this patient as having flu and sent -her home to bed. The patient returned to the ER several hours later and was seen by another member of the staff who diagnosed her as having pneu- alonia and had her admitted to the hospital. Her condition wasconly slightly worse than when Howard saw her in ER. (l9) How responsible is Howard for the patient getting worse? not at all completely responsible responsible l 2 3 4 5 6 7 8 9 lo M: Alan 8.. while on ER duty saw a patient near death in acute diabetic coma with severe Keto-acidosis. He correctly diagnosed the problem and administered the appropriate emergency treatment. The patient recovered and was stabilized on a new diet. (20) How responsible is Alan for the patient's recovery? not at all completely ~ responsible ‘ responsible 12345573910 129 Record your Judgment by question nunber on the separate answer sheet. Situation L: Roberta P. did extensive literature research and review on the roblens of the patients she was seeing on the medical service. ause of this. she was able to suggest for one very seriously ill patient. a recent treatment developnent of which she had Just read. The staff man. Dr. P accepted the suggestion although he had not tried that therapy before. (21) How responsible is Roberta for the patient's rapid improve- ment on the new treatment? not at all completel responsible responsib e 12345678910 (22) How responsible is Dr. P for the patient's improvement on the new treatment? not at all ‘ completel responsible responsib e 12345678910. .-”-----------------.¢--m ---..------------------------- ---.-- 130 Record your Judgnent by question nunber on the separate answer sheet. Situation ii: Jerry R. was assigned to deliver a report in a small group Situation N: seminar on Rednesday. Due to a particularly heavy pt load and consequently long hours at the hospital. he was unable to prepare the report. Tuesday morning. he called the faculty member in charge. Dr. M. and explained his problem. Jerry suggested instead of his report that the group might discuss the problems inherent in the conflicts between clinical duties and studies such as reading. The faculty member accepted the suggestion and invited along for the discussion a local practitioner to also speak on the subJect. The class went well. with the members learning a few techniques for resolving the conflicts of schedule. and feeling better for having discussed them. (23) How responsible is Jerry for the class going well? not at all completely responsible responsible 1 2 3 4 '5 5 7 8 9 10 (24) How responsible is Dr. H for the class going well? not at all completely responsible' responsible 1 2 3 4 5 6 7 8 9 10 After being on call for 36 hours. the last 12 of which were in the E R. Betty 8 saw a pt with acute infection. Due to being tired. the confusion in the room. and the severity of the pt's condition. she failed to check for a history of allergic reactions and administerd penicillin. The pt had a severe reaction went into shock. and died. (25) How responsible is Betty for the pt's death? not at all completely responsible responsible 12345-a7a9m 13]. Record your Judgment by question number on the separate answer sheet Situation 0: Situation P: Jerry T. prescribes a drug with a stimulant effect for a child's illness without telling the mother what to expect. The child was awake and restless all night. and so kept the mother awake. The mother also got increasingly worried and upset about the child's condition. and irritable from her own tiredness. (26) How responsible is Jerry for the mother being upset .and irritable? . not at all completely responsible . , responsible 1 2 3 4 5 6 7 8 9 10 (27) How responsible is the mother far being upset and irritable? not at all completely responsible ‘ responsible 1 2 3 4 5 6 7 8 9 10 While on rounds with a staff man. Dr. 0. Cathy G. realized that he was prescribing a bacteriostatic drug as if it were bacteriocidal. and even so. at too low a dosage for the pt’ 5 - weight and condition. She pointed these facts about to the Dr.. and offered to get the reference. Dr. D. chose to - ignore the student's opinion. and continued treatment as he had planned. Although sure of her facts. Cathy let the matter drop. The pt suffered a relapse of the infection and his. condition seriously deteriorated. (28) How responsible was Cathy for the pt's deterioration? not at all ' completely responsible responsible 12345678910 (29) How responsible was Dr. D for the pt's condition deteriorating? not at all completely responsible responsible 1914::1no1n 132 Record your Judgment by question nurber on the separate answer sheet Situation D: Situation R: Situation 5: Larry J. is quite consistent in attending all the educational meetings at the hospital. He also makes it a point to invite his classmates or encourage them to attend. Some- times Larry learns something which is useful in the treatment of his patients. It certainly makes the persons who arrange the meetings feel that their work is worthwhile to have Larry and others attend. (30) How responsible is Larry's behavior? not at all exceptionally responsible average responsible l. 2 3 ' 4 5 6 7 8 9 lo ‘v‘v — ——————--_——“-‘___—_“—-_----------------------------- Hearing of a disaster. Harry H.. a medical student from another area who happened to be on vacation nearby. presented himself at the emergency room of the hospital and offered to help in . any way he could. (3l) How responsible was Harry's behavior? not at all .exceptionally responsible average responsible l 2 3 4 5 6 7 8 9 10 ‘ Paul C. spends a great deal of time talking to the pts assigned to him. He explains the purpose and process of each procedure he performs during both examination and treatment. He listens to the pt's discussions. sometimes at great length. He tries to answer their questions in as much detail as they can understand. While the pts like this treatment very much. it brings about some difficulties. It seems to the staff that frequently when they want to see him. Paul is with a pt. Also it happens that since Paul takes longer to work up each patient. he does fewer work ups than some of his class mates. (32) How responsible is Paul's behavior? not at all - exceptionally responsible average responsible 1 2 3 4 5 6 7 8 9 10 133 Record your Judgment by question number on the separate answer sheet Situation T. Situation U: Situation V: John R. was assigned a pt for admission to the medical ward during his rotation there. He did a thorough work up. and followed the pt through his hospital stay. John also made an effort to follow the pt after discharge. during his subsequent visits to the out-pt care unit. even though he was on a different rotation. (33) .How responsible was John's behavior? not at all exceptionally responsible average responsible l 2 3 4 5 6 7 8 9 10 Jim T. regularly arrives at the hospital early. sometimes even before the house staff. to review his pt' 5 charts and when possible do some related reading about their problems. Because of this. he is usually prepared to answer the staff man' s questions about his pts. . (34) How responsible is Jim's behavior? not at all exceptionally responsible average responsible 123 4567‘8910 Hhile on rounds one morning.a staff’man. Dr. A. led a group of students into an examininga room where a resident was maintaining a cystoscope in the bladder of a pt. Dr. A announces "Here we have an advanced case of .“ JaCk E. left the room and later confronted Dr. A with the accusation of treating the pt inhumanely -- be referring to him as a 'case of ". by not introducing him by name. by not explaining to him—the students purpose. and by expecting him to endure the painful procedure for so long while each student examined him. Dr. A accused Jack of being insubordinate. conceited. and not learning medical material and reported him to the student performance committee. (35) How responsible was Jack's behavior? - not at all * exceptionally responsible average responsible i 2 3 4 5 6 7 8 9 10 134 Record your Judgment by question number on the separate answer sheet Situation H:' Situation x: (36) How responsible was Dr. A's behavior? not at all exceptionally responsible average responsible‘ l 2 3 '4 5 6 7 8 9 10 Peter F. makes a special point of learning the names of the ward personnel on the services on which he works. He tries to establish a relationship in which they feel free to talk to him about the things they feel are going on which affect him or his pts. including things which are not strictly medical. This encourages them to make suggestions about treatment for his pts. even though he does not always accept their suggestions. It also leads them to report to him things he does which bother them. (37) How responsible is Peter's behavior? not at all exceptionally responsible averagef responsible l 2 3~ 4 5 6 7 8 9 10 When Just about to leave the hospital. Sam R. is invited by . a classmate to stay and talk with him about an especially difficult and acute case which the classmate-is.treating. and which is similar to a case Sam successfully tredted a while ago. Together they hope to determine a treatment plan which might improve the chances for the pt's recovery. although they are currently very poor. Although it is his wedding anniversary.. and Sam has promised his wife he would be home for a special dinner she wanted to prepare. he stays to help with the pt's treatment. (38) How responsible is Sam's behavior? not at all - exceptionally responsible average responsible i 2 3 8 5 6 7 . 8 9 10 (39) Assuming that he knew of Sam's plans for the evening. how responsible is the classmate's behavior? not at all exceptionally responsible average responsible l 2 3 4 5 6 7 8 9 l0 - 135 International Opinion Survey Below are a number of statements about various topics. They have been collected from different groups of people and represent a variety of opinions. There are no right or wrong answers to this questionnaire: for every state- ment there are large numbers of people who agree and disagree. Please indicate whether you agree or disagree by marking an "X" under the agree, or disagree column. If you have no opinion or can't decide. place an "X" in the no opin- lon column. ' On the lBM Answer Sheet. Column "l" indicates agreement; "2" no opinion. and "3" disagree. . Please read each item carefully and be sure that you indicate the re- sponse which most closely corresponds to the way which you personally feel. I. i think the government owes every citizen a decent living. 2. Most students in school would not cheat even if they were sure of getting away with it. 3. When people are nice to me. it is generally because i have done some- thing to make them that way. 4. l definitely cannot go along with the philosophy of "Eat. drink and be merry for tomorrow, who knows?" 5. What has happened to me in the past is my own fault. No one is respon- sible but me. 6. A good leader makes it clear to everybody what their jobs are. 7. By taking an active part in political and social affairs. the people can control world events. .8.' Most students don't realize the extent to which their grades are in- fluenced by accidental happenings. 9.' Capable people who fall to become leaders have not taken advantage of their opportunities. l0. Most repairmen will not overcharge even if they think you are ignorant of their specialty. ll. I believe that the government has been taking over too many of the affairs of private industry. l2. Most parents can be relied upon to carry out their threats of punishment. l.) Agree . . 136 ~ . 2. .No opinion or can't decide 3. Disagree l3. In the long run. people get the respect they deserve in this world. l4. Many of the unhappy things in people's lives are partly due to bad luck. l5. When people are ”mean" to me. it is generally because i have done some- thing to make them that way. l6. Using the Honor System of not having a teacher present during exams would probably result in increased cheating. l7. The average citizen can have an influence on government decisions. l8. The idea that teachers are unfair to students is nonsense. l9. A person can succeed no. matter what his previous background is. 20. Most people can be counted on to do what they say they will do. 2!. My politicalviews are more liberal than most peoplesX 22. i am not as honest with myself as i should be. 23. When someone gets mad.at me. i can usually do something to make him my friend again. 24. Many times we might just as well decide what to do by flipping a coin. ’25. It is seldom profitable to try to be friends with someone if he doesn't want to be. 26. This country has a dark future unless we can attract better people into ' politics. ‘ 27. With enough effort. we can wipe out political corruption. 28. In the case of the well prepared student. there is rarely if ever suth a thing as an unfair test. 29. A good leader molds the opinions of the group he is leading rather than . merely following the wishes of the majority. 30. Most elected public«officiais are really sincere in their campaign promises. 3|. Labor unions have acquired too much power in this country. 32. The United Nations will never be an eftective force in keeping world peace. - ' - Wu “...—.....— .h..-~_fl. .. i. 2. 3. ‘ 33. 34. - 35. 36. 37. 38. 39. 40. 4|. 42. 43. 44. 45. 47. 48. 49. SI. 52. Agree - 137 No opinion or can't decide Disagree it is hard to know whether or not a person really likes you. I have often found that what is going to happen will happen. Every person should be held accountable for his own actions. Parents usually can be relied upon to keep their promises. In the long run, the people are responsible for bad government on a national as well as a local level. Sometimes i can't understand how teachers arrive at the grades they give. i can seldom make other people do the things i want them to do. Most of the time I can't understand why politicians behave the way they do. One should not attack the political beliefs of other people. if we really knew what was going on in international politics. the public would have more reason to be frightened than they now seem to be. People who can't get others to like them don't Understand how to get along with others. I think that life is largely a gamble. Unfortunately. an individual's worth often passes unrecognized no matter how hard he tries. The Judiciary is a place where we can all get unbiased treatment. it is difficult for people to have much control over the things politicians do in office., There is a direct connection between how hard I study and the grades I get. ‘ When i make plans. i am almost certain that I can make them work. Most people would be horrified if they knew how much news the public hears and sees is distorted. Completely free enterprise is the best policy a country can have. Even though we have reports in newspapers. radio and television, it is hard +n na+ nhiah+iun anrnnntc nf nnhlir nupn+c- 2. ;&.J—. L”; A A Agree ' 138 2. No opinion or can't decide 3. Disagree 53. When i get into an argument. it is sometimes my fault. 54. Most people don't realize the extent to which their lives are con- ‘ trolled by accidental happenings. . 55. No matter how hard you try some people just don't like you. 56. Most people answer public opinion polls honestly. 57. All wars could be stopped if countries would put forth more effort to prevent them. 58. Many times exam questions tend to be so unrelated to course work that studnfing is really useless. I 59. i can usually influence people to my way of thinking if I wish. VT Please send me a report of reSults when they're ready. C No thanks. COMMENTS: _ _.__--..._-...,.__._,-, .a- ,fi mag-h...— _.‘ __.___ ____'V_‘ DIRECTIONS: Choose the one you feel it is more important for him to do. If you feel that bothlalternatives are poor. choose the one you think is less poor. 139 ATTITUDES TOWARD LEADERSHIP. In each question are two statements of things that a leader can do. Indicate your answers on the GREEN answer sheet by darkening the number which corresponds to your choice for each item. )0. ii. 12. )3. la, ill 83 '23 l) 2)- To ii ill 83 3 83 ll l3 iii {‘23 ii} To To To To by To To To To To To To To To To To To To To To To To To To To To To To make decisions independently of the group. really be a part of his work group. let workers take time out from the monotony when they wish. allow workers to make decisions only when given explicit authority the leader. take an interest in the worker as a person. maintain definite standards of performance. have his workers do their work the way they think is best. rule with a finn hand. decide in detail how the work shall be done by the workers. let workers make decisions whenever they feel competent. make it clear that he is the leader of the group. have workers settle by themselves most of their Job problems. have the workers settle by themselves most problems. have scheduled rest periods. have his workers do their work the way they think is best. assign specific responsibilities and duties daily. do the important Jobs himself. have workers take their rest periods when they wish. feel he belongs in his group. reward the good workers. have his workers do the work the way they think is best. have the worker depend upon him to make decisions. get the work done on time. be friendly toward his workers. act as he thinks best regardless of the views of his workers. be proud of his work group. give the workers the power to act independently of him. assign wbrl:ers to particular tasks. ,l6. l7. l8. l9. 20. 2]. 22. 23. 24. 25. 26. 27. 28. 30.‘ 3i. 32. ill 2) 53' 83 iii (l) (2) ill (1) ' (2) ll ill 53 To To To To To To To To To 140 do the important jobs himself. let the workers decide how to do each task. leave it up to each iorker to get his share of the work done. set up most projects himself. call the group together to discuss the work. work right alongside the workers. pitch right in with the workers. - plan the work carefully. explain carefully each worker's duties to hhn. To spend some of his time helping to get the work done. To work hard himself. To schedule the work of the men carefully. To be an authority in the type of work the group does. To tell poor workers when their work isn't measuring up to what it should be. To do the same work as his men whenever time allows. To plan how his men will do the Job. To call the group together to discuss the work. To attempt to make his work not too different from the work of his men. To To be respected as.a man of high technical skill in his field. spend over half his time in supervisory activities such as planning and scheduling. To) To To To To To To To To let his workers know how they are doing on their Jobs. spend some of his time helping to get the work done. pass along to his workers information from higher’management. help get the work done. be known as a man of great technical skill in the field. schedule the work to be done. meet with the workers to consider proposed changes. pitch right in with the workers to help make changes. explai‘n the duties of each worker's job to him until he really under- ‘ stands them. To T. To To To To To pitch right in with the workers. perform the same work as the workers whenever possible. plan his day's activities in considerable detail. be known as a skillful trainer. set an example by working hard himself. work right alongside his workers. try out new ideas on the work group. 141. ADJECTIVE CHECKLIST INSTRUCTIONS: 0n the following pages is a list of adJectives or phrases which describe human qualities or behavior. For each one. please mark on the Egg answer sheet number "2“ if you feel the statement is generally true for you: if you feel that the statement is generally false for you. mark number "l". Please make a decision one way or the other for every statement. After you finish check to see that you have marked l§§.responses. d C ‘0 m N a. 0! h u N o o o e e o o o 01 fi -‘ ‘0 m N a. 0" -h (a) N d o . C C C . C C C C C C C C O C . Answering Key: Able to give orders Appreciative Apologetic Able to take care of self Accepts advice readily Able to doubt others Affectionate and understanding Acts important Able to criticize self Admires and imitates others Agrees with everyone Always ashamed of self Very anxious to be approved of Always giving advice I Bitter Bighearted and unselfish Boastful Businesslike Bossy Can be frank and honest Clinging vine Can be strict if necessary Considerate Cold and unfeeling Can complain if necessary .142 Generally True = 2 Generally False = l 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 3a. 39. 4o. 41. 42. 43. 44. 45. 4a. 47. 4a. 49. 50. PLEASE DO NOT OMIT ANY Cooperative Complaining Can be indifferent to others Critical of others Can be obedient Cruel and unkind Dependent Dictatorial Distrusts everybody Dominating Easily embarrassed Eager to get along with others Easily fooled Egotistical and conceited Easily led Encouraging-others EnJoys taking care of others Expects everyone to admire him Faithful fol lower Frequently disappointed Firm but Just Fond of everyone Forceful ' . Friendly Forgives anything ITEMS Answering Key: Frequently angry Friendly all the time Generous to a fault Gives freely of self Good leader Grateful Hard-boiled when necessary Helpful Hard-hearted Hard to convince Hot-tempered Hard to impress Impatient with others' mistakes Independent ‘ Irritable Jealous _ Kind and reassuring Likes responsibility Lacks self-confidence Likes to compete with others Lets others make decisions 3 Likes everybody Likes to be taken care of Loves everyone Makes a good impression .143 Generally True = 2 Generally False = l 76. 77. 78. 79. BO. 81. 82. 83. 84. 85. ‘ 86. 87. 88. 89. 9o. 91. 92. 93. 94. 95. 96. Manages others Meek Modest Hardly ever talks back Often admired Obeys too willingly Often gloomy Outspoken Overprotective of others Often unfriendly Oversympathetic Often helped by others Passive and unaggressive Proud and self-satisfied Always pleasant and agreeable Resentful -. Respected by others Rebels against everything Resents being bossed Self-reliant and assertive Sarcastic Self-punishing *‘Self-confident ’ Self-seeking Shrewd and calculating ‘ PLEASE no NOT OMIT ANY ITEMS 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. .144 Answering Key: Generally True 8 2 Generally False 8 l Self-respecting . 126. Shy 127. Sincere and devoted to friends 128. Selfish 129. Skeptical 130. Sociable and neighborly 131. Slow to forgive a wrong 132. Somewhat snobbish 133. Spineless 134. Stern but fair Spoils people with kindness Straightforward and direct Stubborn Suspicious Too easily influenced by friends Thinks only of self Tender and soft hearted Timid Too lenient with others Touchy and easily hurt Too willing to give to others Tries to be too successful Trusting and eager to please Tries to comfort everyone Usually gives in Very respectful to authority Wants everyone's love Well thought of Wants to be led Will confide in anyone Warm Wants everyone to like him Will believe anyone Well-behaved PLEASE DO NOT OMIT ANY ITEMS APPENDIX C VALIDITY STUDY ON MARS . APPENDIX C Attribution of Responsibility Instructions: On the fbllowing pages are brief descriptions of situations involving medical students with others. For each situation, you are asked to indicate certain qualities about the situation. Whether the outcome is good or bad, mild or severe, and whether it has a direct or anbiguous association with the actor. 0n the attached answer sheet, for each question darken the number’which in- dicates your answer - column 1 indicates the first choice, column 2 indicates the second. PLEASE USE PENCIL ONLY T0 MARK YOUR ANSWERS! You may indicate on the test sheets any comments you wish to make about the descriptions or questions.‘ Your thoughts about responsibility will be help- ful in ultimately defining its measurement and inclusion in the curriculum. Students should please mark their answer sheet with the CHM id number. Faculty should mark their name please. 145 .146 Situation A: Philip 8., while serving his duty night at the hospital. spent the evening in the call room reading material relevant to some problems which his patients had. He did not get any phone calls. and so thought that there were no new admissions or other clinical experiences which he ought to pursue. If he had attempted to call the resident, he would have found that the house staff was in fact very busy that night, and was looking for him although his resident failed to phone the call room. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: __ mild __ severe Would you consider the association between the student and the outcome to be: __ direct _ anbiguous Would you consider the association between the resident and the outcome to be: _'__ direct ‘ __ aubiguous Other cements: Situation 8: Kevin C. did the admissions work up of a pediatrics case which involved a very frightened and lonely child. Kevin returned several times to sit and talk with the child2 and comfort him during his hospital stay. During these visits. the child became . noticeably calmer and looked excited whenever Kevin came into the room. In terms of this story would you consider the outcome to be: good bad Would you consider the outCome to be: __ mild __ severe Would you consider the association between the student and the outcome to be: __ direct __ anbiguous Would you consider the association between the child and the outcome to be: 4 _ direct __ anbiguous Other conments: 10. 11. 12. 13.. _14. 16. .147 Situation C: Fred H. prescribes an expensive medication for a patient's ill- ness. without checking on the patient's financial condition or telling him how much the medication will cost. The patient can- not afford the drugs. but is ashamed to mention it to Fred. With- out the medication. his illness gets worse. In terms of this story would you consider the outcome to be: good ' bad Would you consider the outcome to be: _____mild _____severe Would you consider the association between Fred and the outcome to be: __ direct __ anbiguous Would you consider the association between the patient and the outcome to be: _____direct _____ambiguous Other Comments: Situation D: A faculty member agreed with 061 to give a scheduled lecture on a particular topic because of recent attention to that topic in the news. and new evidence of its importance in clinical medicine. He spent several hours preparing his talk. At the scheduled time how- ever. no students showed up for the lecture. Some did not come be- cause they were busy with other things on their schedule. Others did not come because they were not interested in that topic. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: _mild severe Would you consider the association between those with schedule conflicts and the outcome to be: direct anb'i guous Wbuld you consider the association between those with no interest and the outcome to be: direct - . ambiguous 17. 18. 19. 20. 21. 22. 23. 24. 148 Would you consider the association between OCI and the outcome to be: direct ambiguous Other comments: Situation E: Mike L. did a very thorough work up on a newly admitted patient assigned to him by Dr. Q. In addition to recording complete in- formation, Mike identified several specific problems and planned appropriate treatment which was carried out. In reviewing the chart later, Dr. Q. was able, on the basis of the completeness of the chart, to recognize another problem, which although rare and somewhat esoteric, is life threatening. Dr. Q. sees that the problem is treated, and commends Mike for the completeness of the. records in the chart. In terms of this story would you consider the outcome to be: __ good . __ bad Would you consider the outcome to be: __ mild _ __ severe Would you consider the association between Mike and the outcome to be: direct anbiguous Would you consider the association between Dr. Q. and the outcome to be: direct ambiguous Other comments: Situation F: In preparing the chart notes for a patient, Bernie F. wrote the orders in an illegible manner such that they could not be read. In trying to decipher the orders, a nurse made a mistake in the translation, administered the wrong drug and the patient died. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: mild * - severe Would you consider the association between Bernie and the outcome to be: direct ambiguous 25. 26. 27. 28. 29. 31. 32. 149 Would you consider the association between the nurse and the outcome to be: . direct anbiguous Other comments: Situation 6: Tom P. was assigned a newly admitted patient to work up Just after five o'clock, as he was preparing to go home. He considered doing a quick check to cover the night, and leaving the complete work up til morning. The resident told him he should stay and do the com- plete work up now, so that the chart would be ready for morning rounds; which Tom did. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: __ mild __ severe Would you consider the association between Tom and the outcome to be: __ direct __ ”$190005 , Would you consider the.association between the resident and the outcome to be: __ direct __ anbi guous Other comments: ‘ -. Situation H: While going on rounds with the staff Dr., Robert M. asked, out of curiosity, about the connection between a specific symptom x and .the treatment plan for a patient they had just seen. In explain- ing his answer, Dr. Z realized that he had not taken that connec- tion into account, and changed the patient's therapy. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: __ mild _ severe FWould you consider the association between Robert and the outcome to be: direct ambiguous 33. 35. 37. 150 Would you consider the association between the Dr. and the outcome to be: direct anbiguous Other comments: Situation I: Brenda R. and Stephen C. were discussing the success of their class in , and Brenda was quite clear in expressing her disap- pointment that the class had failed to cover two of the assigned objectives. Without their knowledge, their conversation was over- heard by a faculty member, Dr. X. It happened that Dr. X was sched- uled to teach the next class in their program, and although he had not originally planned to, he saw to it that those two objectives were now covered in his class. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: mild severe Would you consider the association between Brenda and the outcome to be: direct 1 ambiguous Would you consider the association between Dr. X-and the outcome to be: ~direct ambiguous Other comments: Situation J: While on duty in the ER, Howard D. saw a patient with fever, cough, dyspnea, tiredness and dizzyness. These syMptoms are almost identi- cal to several previous cases diagnosed as flu which he had seen that day. He incorrectly diagnosed this patient as having flu and sent her home to bed. The patient returned to the ER several hours . later and was seen by another member of the staff who diagnosed her as having pneumonia and had her admitted to the hospital. Her con- dition was only slightly worse than when Howard saw her in ER. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be:' QQVQ" 41. 42. 43. 44. 45. 41. 151. Would you consider the association between Howard and the outcome to be: direct ambiguous Would you consider the association between the other staff'member and the outcome to be: direct ambiguous Other comments: Situation K: Alan 8., while on ER duty saw a patient near death in acute diabetic coma with severe Keto-acidosis. He correctly diagnosed the problem and administered the appropriate emergency treatment. The patient recovered and was stabilized on a new diet. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: __ mild _ severe Would you consider the association between Alan and the outcome to be:. __ direct __ anbi guous Other comments: Situation L: Roberta P. did extensive literature research and review on the problems of the patients she was seeing on the»medical service. Because of this, she was able to suggest for one very seriously ill patient, a recent treatment development of which she had just read. The staff man, Dr. P accepted the suggestion although he had not tried that therapy before. and the patient improved rapidly. In terms of this story would you consider the outcome to be: good ' bad Would you consider the outcome to be: mild severe ‘Would you consider the association between Roberta and the outcome to be: direct 'ambiguous 48. 49. 51. 52. 53. 1152 Would you consider the association between Dr. P. and the outcome to be: direct ambiguous Other Cements: Situation M: Jerry W. was assigned to deliver a report in a small group seminar on Wednesday. Due to a particularly heavy pt load and consequently long hours at the hospital, he was unable to prepare the report. Tuesday morning, he called the faculty member in charge, Dr. M, and explained his problem. Jerry suggested instead of his report that the group might discuss the problems inherent in the conflicts between clinical duties and studies such as reading. The faculty member accepted the suggestion and invited along for the discussion a local practitioner to also speak on the subject. The class went well, with the members learning a few techniques for resolving the conflicts of schedule, and feeling better for having discussed them. In terms of this story would you consider the outcome to be: good bad - Would you consider the outcome to be: mild ~ severe Would you consider the association between Jerry and the outcome to be: ’ direct ' ambiguous -0 Would you consider the association between Dr. M. and the outcome to be: direct anbi guous Other comments: Situation N: After being on call for 36 hours, the last 12 of whicthere in the ER, Betty 8 saw a pt with acute infection. Due to being tired, the confusion in the room, and the severity of the pt's condition, she failed to check for a history of allergic reactions and administered penicillin. The pt had a severe reaction, went into shock, and died. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: mild _ severe 55. 56. 57. 58. 59. 60. 61. .153 Would you consider the association between Betty and the outcome to be: direct ambiguous Other comments: Situation 0: Jerry T. prescribes a drug with a stimulant effect for a child's illness without telling the mother what to expect. The child was awake and restless all night, and so kept the mother awake. The mother also got increasingly worried and upset about the child's condition, and irritable from her own tiredness. In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: __ mi 1d __ severe Would you consider the association between Jerry and the outcome to be: _ direct __ anbiguous. Would you consider the association between the mother and the outcome to be: _ direct _ anbi guous Other comments: Situation P: While on rounds with a staff man, Dr. 0, Cathy G. realized that he was prescribing a bacteriostatic drug as if it were bacteriocidal, and even so, at too low a dosage for the pt's weight and condition. She pointed these facts out to the Dr., and offered to get the ref- erence. Dr. 0. chose to ignore the student's opinion, and continued treatment as he had planned. Although sure of her facts, Cathy let the matter drop. The pt suffered a relapse of the infection and his condition seriously deteriorated. In terms of this story would you consider the outcome to be: good . bad Would you consider the outcome to be: ' mild severe 154 It. Would you consider the association betwaan Cathy and the pt's deterioration to be: __ direct __ anhiouous l3. Would you consider the association between Dr. 0 and the pt‘s deterioration to be: direct antiguous 7. Other counts: Situation 0: Larry J. is quite consistent in attending all the educational meat- i s at the hospital. He also makes it a point to invite his class- as as or encourage then toe-.ttend. Sometimes Larry learns something which is useful 11 the treatment of his atients. It certainly makes the persons who arrange the meetings fee that their work is worth- while to have Larry and other attend. In terns of this story would you consider the outcue to be: __ 9°04 __ baa .Would you consider the outcue to be: __ wild __ ...." Would you consider the association between Larry and the outcome to be: __ direct ___enbi guous Other ments: Situation A: Heeri of a disaster. Harry 14.. a medical student free another area w happened to be on vacation nearby. presented himself at the anergency roan of the hospital and offered to help in anyway he could. In terms of this story would you consider the outcue to be: __ 11°04 __ bad Would you consider the outcone to be: __ aild __ severe' Would you consider the association between Harry and the outcoae to be: __ direct __ alibi guous Other canents: 70. 71. 72. 73. 74. 75. 155 :Situation S: Paul C. spends a great deal of time talking to the pts assigned to him. He explains the purpose and process of each procedure he per- forms during both examination and treatment. He listens to the pt's discussions, sometimes at great length. He tries to answer their questions in as much detail as they can understand. While the pts like this treatment very much, it brings about some difficulties. It seems to the staff that frequently when they want to see him, Paul is with a pt. Also it happens that since Paul takes longer to work up each patient, he does fewer work ups than some of his class mates. In terms of this story would you consider the outcome to be: ____ good ____ bad Would you consider the outcome to be: _____mild _____severe Would you consider the association between Paul and the outcome to be: direct ambiguous Other comments: Situation T: John R. was assigned a pt for admission to the medical ward during his rotation there. He did a thorough work up, and followed the pt through his hospital stay. John also made an effort to follow the pt after discharge, during his subsequent visits to the out-pt care unit, even though he was on a different rotation. In terms of this story would you consider the outcome to be: ____ good _____bad Would you consider the outcome to be: _____mild _____severe Would you consider the association between John and the outcome to be: direct ambiguous Other comments: Situation U: Jim T. regularly arrives at the hospital early, sometimes even before the house staff, to review his pt's charts and when pos— sible do some related reading about their problems. Because of this, he is usually prepared to answer the staff man's questions about his pts. hm; ..‘_ 76. 77. 78. 81. 82. 1156 In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: _ mild __ severe Would you consider the association between Jim and the outcome to be: _____direct _____ambiguous Other comments: Situation V: While on rounds one morning, a staff man, Dr. A, led a group of students into an examining room where a resident was maintaining a cystoscope in the bladder of a pt. Dr. A announces "Here we have an advanced case of ‘ ‘ .“ Jack E. left the room and later confronted Dr. A with the accusation of treating the pt in- humanely -- by referring to him as a "case of ", by not introducing him by name, by not explaining to him the students' purpose, and by expecting him to endure the painful procedure for -so long while each student examined him. Or. A accused Jack of being insubordinate, conceited, and not learning medical material and reported him to the student performance committee. In terms of this story would you consider the outcome to be: good bad -. Would you consider the outcome to be: __ mild __ severe Would you consider the association between Dr. A and the outcome to be: 1 __ direct __ anb'i guous Would you consider the association between Jack and the outcome to be: _____direct ____ ambiguous Other comments: 83. 85. 87. 88. .157 Situation W: Peter F. makes a special point of learning the names of the ward personnel on the services on which he works. He tries to establish a relationship in which they feel free to talk to him about the things they feel are going on which affect him or his pts, includ- ing things which are not strictly medical. This encourages them to make suggestions about treatment for his pts, even though he does not always accept their suggestions. It also leads them to report to him things he does which bother them. - In terms of this story would you consider the outcome to be: good bad Would you consider the outcome to be: __ mild __ severe Would you consider the association between Peter and the outcome to be: __ direct __ anbi guous Other comments: Situation X: When just about to leave the hospital, Sam R. is invited by a classmate to stay and talk with him about an especially difficult and acute case which the classmate is treating, and which is simi- lar to a case Sam successfully treated a while ago. Together they hape to determine a treatment plan which might improve the chances for the pt's recovery, although they are currently very poor. Al- though it is his wedding anniversary, and Sam has promised his wife he would be home for a special dinner she wanted to prepare, he stays to help with the pt's treatment. In terms of this story would you consider the outcome to be: good " bad Would you consider the outcome to be: __ mild . __ severe Would you consider the association between Sam and the outcome to be: __ direct __ anbiguous Would you consider the association between the classmate and the outcome to be: __ direct __ anbi guous Other comments: APPENDIX D CORRELATIONS AMONG STORY VARIABLES mn.1 NH. oH.1 nH. mo. mm. HH. vH. NH. mH. Ho.1 VH.1 oo.1 muHHHnHmcommom dad H no.1 oH. no.1 oo. mH.1 Ho.1 vo.1 no.1 Ho. no. no. NH. :oHuoquHmcoo dad H 0N.I NH. mo. mo.1 mo. HH. mo. mH. HH. Ho.l HH. ZOO AUH H OH. Ho. no. NH. mo. 00.1 no. mH. vm. HH. >OA AUH H vm. om. mv. om. nm. mn. no.1 no.1 No. BOHmOH H «H. mH. mN.1 mv. no. no.1 Ho.1 no. m moH H on. Hm. NH. mm. no.1 no.1 mo. v moH H oH. no.1 nN. HH.1 no.1 no.1 n moH H o~.1 oH. Ho. no.1 oo.1 N moH H mH. no.1 no.1 no.1 H mOH H we. no.1 0H. umDHB mOH H Hn. an. ucmvsum mud: H hm. 0>Humfiuoz mud: H Humamo mad: m. m m m m. m m m m m m. m m w 1 1 1 T S Q” S S S S S H W W L S H 3 m 1 O .5 P re 7. I .¢ 3 O O L 1 S N 3 S u W A n 3 o e d s s n 1 n O I. 3 p m s u D. a E Q s a u 3 I I. 1 3 I. a. P A T. 3 a I T I. o 3 u K moanowwo> xuoum m:OE< mcoHuonuuou H10 mHQMB Q NHozmmm/w 158 REFERENCES REFERENCES Allport, G. W. Patterns and growth in personality. New York: HBTt, Rhinehart, and Winston, 1961. Angyal, A. Foundations for a science of personality. New York: Commonwealth fund,71941. Baron, R. A. Authoritarianism, locus of control, and risk taking. Journal of Psychology, 1968, 68, 141-143. Battle, B., & Rotter, J. B. Children's feelings of personal control as related to social class and ethnic group. Journal of Personality, 1963, 31, 482-490. Bem, D. J. A personal communication, 1970. Bierman, R. 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