The Core Competencies: Why, What, and How

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The Core Competencies Why, What, and How?
CORD-EM Best Practices in Residency Training
Reaching for Excellence February 2003
Arthur Sanders, MD Professor of Emergency
Medicine University of Arizona COM Chair, RRC-EM

• Pamela L. Dyne, MD
• Associate Professor of Medicine
• D. Geffen School of Medicine at UCLA
• Residency Director
• UCLA/Olive View-UCLA Emergency Medicine

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OUTCOMES SHIFT - WHY?

• Accountability - Our system of medical education
  relies heavily on considerable public funding. 
  We therefore need to be accountable to the public
  in terms of both meeting public needs and
  preparing well-qualified new physicians in the
  most cost-effective way possible.
• Process vs. Outcome - Measuring program quality
  by examining structure and process is not a
  direct or complete measure of the quality of the
  educational outcomes of a program.
• ACGME

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OUTCOMES SHIFT - WHY?

• Need for Better Measures of Quality -
  Availability of educational outcomes-based data
  is necessary to inform policymakers and others
  who have become increasingly focused on issues
  related to funding for medical education, and,
  most recently, on patient safety.
• It is incumbent upon us as medical educators to
  demonstrate the effectiveness of our educational
  programs and to be held accountable for our work.
  
• ACGME

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QUALITY IMPROVEMENT

• Structure - institution, number of faculty,
  patient volume and acuity, number of procedures,
  curriculum schedule
• Process - resident shifts and responsibilities,
  block rotations, conference attendance, feedback
  and evaluations, teaching methods, etc.
• Outcome - board certification, successful
  completion of program, etc.

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ACGME COMPETENCIES

• Minimal Threshold Model for GME accreditation
• Minimal processes for education - curriculum,
  conferences, patient populations, procedures,
  faculty, etc.
• Program has the potential to educate competent
  physicians

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ACGME OUTCOMES

• Educational Outcomes - Evidence showing the
  degree to which programs purposes and objectives
  are or are not being attained, including
  achievement of appropriate skills and
  competencies by students.
  
  
• ACGME Outcomes Project

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ACGME COMPETENCIES

• In the competency-based model programs will be
  asked to show how residents have achieved
  competency-based educational objectives and in
  turn, how programs use information drawn from
  evaluation of those objectives to improve the
  educational experience of the residents. Stated
  another way, the minimal threshold model
  identifies whether a program has the potential to
  educate residents the competency-based model
  examines whether the program is actually
  educating them.
• ACGME Outcome Project

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ACGME COMPETENCIES

• Competency Based Model
• Educational objectives will need to be competency
  based
• How programs evaluate competencies based on the
  educational objectives
• How programs use evaluation information to
  improve the educational experience.

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IDENTIFYING COMPETENCIES

• Identifying the competencies was stimulated by
  increased attention to how adequately physicians
  are prepared to practice medicine in the changing
  health care delivery system.
• The ACGME derived its general competencies
  through a careful study of existing research on
  general competencies for physicians.  It also
  gathered input on the proposed competencies from
  various constituencies and stakeholders of GME.
• From this process, the Outcomes Project Advisory
  Committee identified six general competencies
  that were subsequently endorsed by the ACGME in
  February 1999.
• ACGME

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Program Requirements-draft

• Programs must define the specific knowledge,
  skills, behaviors, and attitudes required and
  provide educational experiences as needed in
  order for their residents to demonstrate the
  following

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The ACGME General Competencies

• Patient care
• Medical knowledge
• Practice-based learning and improvement
• Interpersonal and communication skills
• Professionalism
• Systems-based practice

(What are the competencies for EM?)
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ACGME Assessment Toolbox

• 360 evaluation
• Chart stimulated recall
• Checklist eval
• Global rating of live or recorded performance
• OSCE
• Procedure, operative or case logs

• Patient surveys
• Portfolios
• Record review
• Simulations and models
• Standardized oral exam
• Standardized patients
• Written exam (MCQ)

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EMERGENCY MEDICINE COMPETENCIES

• Who defines the specific EM competencies?
• The Model of the Clinical Practice of Emergency
  Medicine
• RRC-EM Task Force

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and CORD-EM is at the table

• The ACGME Core Competencies Getting Ahead of
  the CurveCORD-EM, March 2002
• Academic Emergency Medicine, November 2002, Vol.
  9, No.11

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Patient Care Goals

• ACGME Residents must be able to provide patient
  care that is effective, appropriate, and
  compassionate for the treatment of health
  problems and promotion of health.
• CORD EM residents must be able to provide
  patient care that is timely, effective,
  appropriate, and compassionate for the management
  of health problems and promotion of health.

King, Schiavone, Counselman, Panecek, Patient
Care Competency in Emergency Medicine Graduate
Medical Education Results of a Consensus Group
on Patient Care. AEM 200291227-1235
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EM Patient Care Objectives

• Gather accurate, essential information in a
  timely manner from all sources, including medical
  interviews, physical examinations,
  out-of-hospital care personnel, medical records,
  and diagnostic/therapeutic procedures.
• Integrate diagnostic information and generate an
  appropriate differential diagnosis.
• Implement an effective patient management plan
  including therapy, appropriate consultation,
  disposition, and pt. education

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EM Patient Care Objectives

• Competently perform the diagnostic and
  therapeutic procedures and emergency
  stabilization considered essential to the
  practice of EM.
• Demonstrate the ability to appropriately
  prioritize and stabilize multiple patients and
  perform other responsibilities simultaneously.

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EM Patient Care Assessment

• Checklist Evaluation of Live Performance (Direct
  Observation)
• Snapshot approach using on-shift attending and
  repeated isolated mini-evals
• Comprehensive approach involving a non-on-shift
  faculty member for several hours at a time

• Advantages real clinical environment, time
  efficient for residents and faculty (potentially)
• Concerns Hawthorne effect, observer training
  bias, disturbance of physician-patient
  relationship

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EM Patient Care Assessment

• Simulations and Models with D.O.
• Secondary methods

procedures and stabilization
ALL toolbox items relevant patient surveys,
record review, 360 eval, and procedure logs
limited applicability
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Medical Knowledge Goals

• ACGME Residents must demonstrate knowledge
  about established and evolving biomedical,
  clinical, and cognate (eg. epidemiological and
  social-behavioral) sciences and the application
  of this knowledge to patient care.

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EM Medical Knowledge Goals

• CORD-EM Residents are expected to formulate an
  appropriate DDx with special attention to
  life-threatening conditions, demonstrate the
  ability to utilize available medical resources
  effectively and concurrent with patient care, and
  apply this knowledge to clinical problem solving
  and clinical decision-making.

Wagner, MJ, Thomas, HA, Application of the
Medical Knowledge General Competency to Emergency
Medicine, AEM 200291236-1241
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EM Medical Knowledge Objectives

• Identify life threatening conditions
• Identify the most likely diagnosis
• Synthesize acquired patient data
• Identify how and when to access current medical
  information
• Properly sequence critical actions in patient
  care
• Generate a DDx for an undifferentiated patient
• Complete disposition of patients using available
  resources

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EM Medical Knowledge Assessment

• Checklist Evaluation of Live Performance (Direct
  Observation)
• Progressive questioning by on-shift attending
• Comprehensive approach involving a non-on-shift
  faculty member for several hours at a time

• Beyond the usual applied questions
• Content area specific approach

• Structured clinical assessment

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EM Medical Knowledge Assessment

• Objective standardized examination (OSE)
• National In-Service exam
• Locally written tests
• Topic specific modular curriculum with exams
• Computer-based learning modules with exams

• Advantages objective, criterion referenced, prep
  for the real thing, easy to track and
  provide data to RRC
• Concerns labor and time intensive, (external
  locus of control for learning may not promote
  development of career learning habits)

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EM Medical Knowledge Assessment

• Simulations and models
• Procedures and low-frequency, critical content
  areas
• OSCE, SP, computer models
• Needs objective evaluation tool development
• Classroom observation
• Chart-stimulated recall
• Global rating form
• 360 eval
• portfolios

Inconsistencies in style vs. knowledge?
needs scoring protocol
less precise, halo vs. millstone effect
TNTC confounders
? for remediation
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Practice-Based Learning and Improvement Goals

• ACGME Residents must be able to investigate and
  evaluate their patient care practices, appraise
  and assimilate scientific evidence, and improve
  their patient care practices.

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EM Practice-Based Learning and Improvement
Objectives

• Analyze and assess your practice experience and
  perform practice-based improvement.
• Locate, appraise, and utilize scientific evidence
  related to your patients health problems and the
  larger population from which they are drawn.
• Apply knowledge of study design and statistical
  methods to critically appraise medical
  literature.

Hayden, SR, Dufel, S, Shih, R, Definitions and
Competencies for Practice-based learning and
improvement, AEM 200291242-1248
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EM Practice-Based Learning and Improvement
Objectives

• Utilize information technology to enhance your
  education and improve patient care.
• Facilitate the learning of students, colleagues,
  and other health care professionals in emergency
  medicine principles and practice.

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EM Practice-Based Learning and Improvement
Assessment
QA projects, individual learning plans, journal
club write-ups, etcself-reflection of learning
and how their EM practice might change as a result

• Portfolio
• CSR
• 360 global eval
• Computer simulation

Focus on decision-making, test interpretation,
rationale for diagnostic and therapeutic
interventions educational prescription
frequency, efficiency, and utilization of
evidence in clinical decision-making lectures,
bedside teaching
Web-based modules requiring searching, analyzing
medical info resources monitoring software to
automatically record computer sessions
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Interpersonal and Communication Skills Goals

• ACGME Residents must be able to demonstrate
  interpersonal and communication skills that
  result in effective information exchange and
  teaming with patients, their families, and
  professional associates.

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EM Interpersonal and Communication Skills
Objectives

• Demonstrate the ability to respectfully,
  effectively, and efficiently develop a
  therapeutic relationship with patients and their
  families
• Demonstrate respect for diversity and cultural,
  ethnic, spiritual, emotional, and age-specific
  differences in patients and other members of the
  health care team.
• Demonstrate effective listening skills and be
  able to elicit and provide information using
  verbal, nonverbal, written, and technological
  skills.  

Hobgood, Riviello, Jouriles, Hamilton, Assessment
of Communication and Interpersonal Skills
Competencies. AEM 200291257-1269
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EM Interpersonal and Communication
SkillsObjectives

• Demonstrate ability to develop flexible
  communication strategies and be able to adjust
  them based on the clinical situation
• Demonstrate effective participation in and
  leadership of the health care team
• Demonstrate ability to elicit patients
  motivation for seeking health care
• Demonstrate ability to negotiate as well as
  resolve conflicts
• Demonstrate effective written communication
  skills with other providers and to effectively
  summarize for the patient upon discharge

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EM Interpersonal and Communication
SkillsObjectives

• Demonstrate ability to effectively use the
  feedback provided by others
• Demonstrate ability to handle situations unique
  to EM

• High-risk refusal of care patients
• Communication with out-of-hospital personnel and
  non-medical personnel
• Acutely psychotic patients
• Disaster medicine

Intoxicated patients AMS Delivering bad
news Difficulties with consultants DNR/end-of-life
decisions Patients with communications barriers
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EM Interpersonal and Communication
SkillsAssessment

• Direct Observation (D.O.)
• Standardized Patients (SP)
• simulations and models, OSCE, CSR, standardized
  oral examinations

• on-shift or not-on-shift attending direct
  feedback
• expensive faculty time, Hawthorne effect,
  disrupts doc/pt relationship, lack of
  objective measures

practice low-frequency/high stakes events (death
telling)
especially for conflict resolution and
consultations
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Professionalism Goals

• ACGME Residents must demonstrate a commitment
  to carrying out professional responsibilities,
  adherence to ethical principles, and sensitivity
  to a diverse patient population.

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EM Professionalism Model Behaviors

• Arrives on time and prepared to work
• Appropriate (inoffensive) dress and cleanliness
• Willingly sees patients throughout the entire
  shift
• Appropriate sign-outs, both giving and receiving
• Observable patient advocacy in disposition
• Appropriate use of symptomatic care
• Completes medical records honestly and punctually
• Treats patients/families/staff/paraprofessional
  personnel with respect

Larkin, Binder, Houry, Adams, Defining and
evaluating professionalism A core competency for
graduate emergency medical education. AEM
200291249-1256
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EM Professionalism Model Behaviors

• Protects staff/family/patients
  interests/confidentiality
• Demonstrates sensitivity to patients pain,
  emotional state, and gender/ethnicity issues
• Actively seeks feedback and immediately
  self-corrects
• Shakes hands with the patient and introduces
  himself or herself to the patient and family
• Effectively coordinates team
• Unconditional positive regard for the patient,
  family, staff, and consultants
• Accepts responsibility/accountability
• Recognizes the influence of marketing and
  advertising

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EM Professionalism Model Behaviors

• Open/responsive to input/feedback of other team
  members, patients, families, and peers
• Uses humor/language appropriately
• Discusses death honestly, sensitively, patiently,
  and compassionately
• Participates in peer-review process
• Fairness in recruitment of residents, faculty,
  and staff

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EM Professionalism Assessment

• Knowledge and awareness of professional norms and
  behavior
• Moral reasoning and professional capacity
• Professional behavior

written testing detached from clinical setting
simulations OSCE, computerized, oral exams,
SPs ??? Gender bias in approach justice vs. care
D.O. 360 global eval SPs
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Systems-Based Practice Goals

• ACGME Residents must demonstrate an awareness
  of and responsiveness to the larger context and
  system of health care and the ability to
  effectively call on system resources to provide
  care that is of optimal value.
• CORD-EM EM Residents must demonstrate an
  awareness of health care systems and the ability
  to effectively mobilize system resources to
  provide optimal care.

Dyne, PL, Strauss, RW, Rinnert, S, Systems-based
practice The sixth core competency. AEM
200291270-1277
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EM Systems-Based Practice Objectives

• Understand, access, appropriately utilize, and
  evaluate the effectiveness of the resources,
  providers, and systems necessary to provide
  optimal emergency care.
• Understand the different medical practice models
  and delivery systems and how to best utilize them
  to care for the individual patient.

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EM Systems-Based Practice Objectives

• Practice cost-effective health care and resource
  allocation that does not compromise quality care.
• Advocate for and facilitate patients advancement
  through the health care system.

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EM Systems-Based Practice Assessment

• Portfolios
• Requires resident self-reflection
• Inclusion items for SBP admin/QA project,
  relevant scholarly project, patient care example,
  etc.
• Evaluation of success standardized vs. based on
  the educational process

content selection establishes a pattern for
continued life-long learning
faculty developmentteach the teacher
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EM Systems-Based Practice Assessment

• Direct Observation (D.O.)
• Global rating
• 360 evals
• Standardized oral exams

especially for multitasking and team-management
assessment instrument needs development
takes advantage of peer pressure, very labor
intensive
modify existing format to include SBP content
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What should CORD do?

• Develop validated and reliable assessment
  instruments
• Validated checklist of live performance
• New simulators and/or computer-based interactive
  programs
• Validated portfolio assessment
• Attention to low-frequency but critical skills
  assessment
• Focus on faculty development
• Teach from the middle

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WHAT SHOULD PROGRAMS DO?

• Begin the think in terms of competencies
• Evaluate ACGME toolbox for assessment
• Educational faculty retreats
• Develop measurable learning objectives
• Assess tools for measuring objectives
• DO NOT DO NOTHING

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OUTCOME QUESTIONS

• Do the residents achieve the learning objectives
  set by the program?
• What evidence can the program provide that it
  does so?
• How does the program demonstrate continuous
  improvement in its educational processes?

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Transforming the Accreditation Process

• The shift from emphasis on structure-and-process
  components to emphasis on outcomes will be a
  gradual transition. The need for programs to
  provide evidence of structures and processes will
  not disappear but will gradually become less
  critical to the overall accreditation process.