Resident Proficiency in Assessing Medical Decision-Making Capacity: A Needs Assessment and Educational Intervention

Background Medical decision-making capacity is fundamental to informed consent, patient autonomy, and ethical care, yet incapacity is frequently underrecognized. Despite encountering patients requiring capacity assessments, residents often receive limited formal training. Objective The objectives of this study are to identify gaps in resident knowledge, confidence, and perceived barriers to capacity assessment and evaluate the impact of a targeted educational intervention. Methods This IRB-approved quality improvement study (2025-2026) included residents from two family medicine and one internal medicine residency program (83 eligible participants). A voluntary pre-survey assessed resident experience and educational needs. Primary measures include self-reported knowledge, confidence, understanding of Appelbaum's criteria, distinction between capacity and competence, documentation skills, and legal/ethical considerations using 5-point Likert scales. Secondary measures included prior training, frequency of capacity assessments, perceived barriers, and educational preferences. Survey findings were utilized to create a targeted educational intervention. This was designed to be a one-hour interactive, case-based didactic addressing Appelbaum's four components of capacity, capacity versus competence, documentation, and legal/ethical considerations. A voluntary post-survey was administered to compare primary measures to pre-survey results. The population size for the educational intervention and post-survey had a maximum of 63 participants due to one family medicine program withdrawing. Independent t-tests compared pre- and post-intervention responses.  Results Seventy-one residents (86% response rate) completed the pre-survey and 40 (63% response rate) completed the post-survey. Although 58% (n=41) reported performing capacity assessments weekly, no prior training was reported by 63% of PGY1s (n=15), 46% of PGY2s (n=12), and 19% of PGY3s (n=4). Common barriers included legal/ethical aspects at 70% (n=50) and time constraints at 62% (n=44). Mean scores improved significantly after the intervention for understanding of capacity components (3.44-4.55), capacity versus competence (3.15-4.60), documentation (3.00-4.68), legal/ethical considerations (2.99-4.70), confidence (3.28-4.62), and knowledge (2.17-4.78) (all p<0.001). Conclusions Residents frequently perform capacity assessments despite limited formal training. An educational intervention significantly improved self-reported knowledge and confidence, supporting incorporation of structured capacity assessment curricula into graduate medical education.