You Can't Fix by Analysis What You've Spoiled by Design: Developing Survey Instruments and Collecting Validity Evidence.

S urveys are frequently used in graduate medical education (GME). Examples include resident satisfaction surveys, resident work-hour questionnaires, trainee self-assessments, and end-of-rotation evaluations. Survey instruments are also widely used in GME research. A review of the last 7 issues of JGME indicates that of the 64 articles categorized as Original Research, 50 (77%) included surveys as part of the study design. Despite the many uses of surveys in GME, the medical education literature provides limited guidance on survey design, and many surveys fail to use a rigorous methodology or best practices in survey design. As a result, the reliability and validity of many medical education surveys are uncertain. When surveys are not well designed, the data obtained from them may not be reproducible and may fail to capture the essence of the attitude, opinion, or behavior the survey developer is attempting to measure. A plethora of factors affecting reliability and validity in surveys includes, but is not limited to, poor question wording, confusing question layout, and inadequate response options. Ultimately, these problems negatively impact the reliability and validity of survey data, making it difficult to draw useful conclusions. With these problems in mind, the aim of the present editorial is to outline a systematic process for developing and collecting reliability and validity evidence for survey instruments used in GME and GME research. The term survey is quite broad and could include questions used in a phone interview, the set of items used in a focus group, and the items on a self-administered patient survey. In this editorial, we limit our discussion to selfadministered surveys, which are also sometimes referred to as questionnaires. The goals of any good questionnaire should be to develop a set of items that every respondent will interpret the same way, respond to accurately, and be willing and motivated to answer. The 6 questions below, although not intended to address all aspects of survey design, are meant to help guide the novice survey developer through the survey design process. Addressing each of these questions systematically will optimize the quality of GME surveys and improve the chances of collecting survey data with evidence of reliability and validity. A graphic depiction of the process described below is presented in the FIGURE.