Linda Larson Carr, PhD

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Core Competencies for Graduate Medical Education
What do Coordinators Need to Know?MECAzBanner
Good Samaritan Medical CenterApril 24, 2008

• Linda Larson Carr, PhD
• Office of Academic Faculty Development
• Academic Affairs

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Slides 8 - 42 are from the presentation
Demystifying the Competencies Practical
Strategies for Implementationgiven by Barbara
L. Joyce, PhD and John D. Buckley, MD, MPH at
the ACGME Educational Conference in February
2008.
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Objectives

• Share updates on the ACGME Outcomes Project
  rationale, phases, assessment measures
• Describe examples of learning activities
  appropriate for selected competencies in various
  programs
• Describe opportunities for enhancing the learning
  environment to maximize CBE

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Successful Implementation Assessment Requires a
Team Approach
ProgramDirector
Faculty or other HC Provider
Coordinator
Resident
Who is missing?
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The ACGME Outcome Project

• A long-term initiative by which the ACGME is
  increasing emphasis on educational outcomes in
  the accreditation of residency education
  programs.

• The six general competencies focus on how to
  adequately prepare physicians for practicing
  medicine in the changing health care delivery
  system.

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ACGME Outcome Project
Which phase should we be in now?

• Phase I (7/2001 6/2002)Define objectives
  begin integration
• Phase II (7/2002 6/2006)Improve evaluation
  processes provide aggregated performance data
• Phase III (7/2006 6/2011)Use resident data as
  basis for improvement - begin to use external
  quality measures
• Phase IV (7/2011 Beyond)Involve community in
  building knowledge about good GME identify
  benchmark programs
  http//www.acgme.org/outcome/

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The Competencies Continuum

• Undergraduate Med Ed
• Graduate Med Ed
• Continuing Med Ed
• Recertification /Licensure

GME
UME
CME
Recert.
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Competency-Based Education

• Implies that skills, attitudes, and behaviors are
  as important as knowledge base
• Incorporates formal assessments of desired
  competencies
• Competencies are integrated throughout curriculum

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Characteristics of CBE vs. Discipline-Based
Education

• COMPETENCY-BASED EDUCATION
• Focus is learning
• Successive stages of mastery integration into
  practice
• Self-directed
• Outcomes based
• Demonstration of competency

• DISCIPLINE-BASED EDUCATION
• Focus is behavioral
• Accumulation of isolated facts skills breadth
  of exposure
• Teacher-directed
• Content based
• Meeting requirements

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The underlying assumption is that whatever we
measure, we tend to improve. (D. Leach,
ACGME Outcome Project)
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Competency-based approach

• What do you want your end product to be?

Start here
Knowledge Attributes Skills Attitudes Behaviors
Objectives Tasks
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Where to start

• Start by asking the question, What are the
  skills, attitudes, knowledge, and behaviors that
  we think are necessary for all graduating medical
  residents?

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Another way to think about it

• What is it that we expect our medical
  students/residents/fellows to get out of
• Lectures
• Educational Grand Rounds
• Morning Report
• Clinical Experiences

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• Does your curriculum provide opportunities for
  your faculty to model
• Good communication skills
• Problem solving
• Professionalism
• Life-long learning
• Broad knowledge base

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• The single most important contribution to the
  learning of medical residents is the modeling of
  professional skills, behaviors, knowledge, and
  attitudes by the residency faculty!

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So What are the Core Medical Competencies that
Need to be Addressed in the Graduate Medical
Curriculum?
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The Six Competencies

• TRADITIONAL DOMAINSMedical KnowledgePatient
  Care
• BEHAVIORAL PROFESSIONAL DOMAINSInterpersonal
  Communication SkillsProfessionalism
• QUALITY DOMAINSPractice-based Learning
  ImprovementSystems Based Practice

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Core Competencies Core Values

• Knowledge of disease-associated conditions
• Knowledge of pathophysiology
• Clinical problem solving
• Interpretation of data
• Knowledge of the role of the physician specialist
• Communication with other members of the health
  care team
• Ability to access relevant information sources
• Ability to incorporate new knowledge as it
  becomes available
• Etc.

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PAIR and SHARE

• Of the six competencies, which ones are the most
  challenging for your program to teach and
  measure and why?

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Practice-based Learning Improvement
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Practice-Based Learning and Improvement

• Quality Improvement
• Evidence based medicine
• Teaching others (patients, students, junior
  residents)
• Developing habits of life long learning and
  self-reflection

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What does this look like in different specialties?

• QI Activities
• Pathology
• Residents form teams and actively engage in
  process improvement to reduce wait time for
  patients getting results from breast biopsy
  Participate in Quality Expo
• OB/GYN
• M M drives quality improvement activities of
  residents
• Internal Medicine
• Practice Improvement Modules

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What does this look like in different specialties?

• EBM
• Internal Medicine Course in EBM
• Self Reflection
• Surgery Development of resident learning plans
• All Specialties
• Evidence based medicine journal club
• Development of learning plans
• QI project
• Residents as teachers activity

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PBLI Self Assessment

• Do residents actively participate in Quality
  Improvement initiatives?
• Do you have EBM Journal Club? Do you use EBM when
  teaching?
• Do you have structured activities where residents
  learn to teach others?
• How do residents reflect on and improve their
  practice?
• Do residents develop learning plans to review
  with advisor/PD?
• Do you have an assessment tool for assessing a
  residents teaching skills?

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Systems-based Practice
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Systems-Based Practice

• Understanding the Health Care Delivery System
• Patient Advocacy
• Working in Inter-professional Teams
• Patient Safety

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What does this look like in different specialties?

• Health System
• Internal Medicine collaborative rounding
  course on business aspects of medicine
• Surgery identification of systems issues during
  M M in-situ simulation
• Cost-effective health care
• A I review of prescribing patterns of faculty
  and fellows discussion and recommendations to
  pharmacy
• re formulary
• Family Medicine practice management curriculum

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What does this look like in different specialties?

• Patient Safety and Advocacy
• All resident present root cause analysis of
  near miss or sentinel event
• All Link M M conference to QI group projects
• Teamwork
• Internal Medicine collaborative rounding
• All training in Hand-offs or Crew Resource
  Management

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Systems-Based Practice Self Assessment

• Do residents actively participate in M M?
• Do residents have a learning activity that
  addresses
• Cost containment
• Risk-benefit analysis
• Do residents have a learning activity that
  addresses inter-professional teamwork?
• Do residents have a learning activity that
  addresses patient advocacy?

Reflect
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Assessment

• How do I know a resident is competent?

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The Challenge - Assessment

• Identification of core competencies requires
  opportunities for assessment
• Multiple choice examinations are often not
  sufficient to evaluate skills, attitudes, and
  behaviors
• Its difficult to make meaningful assessments of
  skills, attitudes, and behaviors for large groups
  of students

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• Formal assessment adds value to a curricular
  component
• If its important, it should be assessed
• Residents learn quickly that things that are not
  assessed are neither valued nor important

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Assessment Pearls

• Assess residents longitudinally
• Use multiple evaluations
• Use multiple evaluators who give different
  perspectives

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And in the end

• You have enough data to
• paint a picture of competence

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What is an assessment system?

• An assessment system
• Is a collection of assessment tools which measure
  a residents performance
• Defines who the evaluators are
• Describes what performance will be evaluated
• Indicates how often the evaluation occurs

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A core Assessment System

• Method Competency
• Global Clinical Performance Ratings All
• Multi-source/360 ICS, Prof
• Direct Focused Observation PC, Prof, ICS
• Case/Procedure Logs PC
• Cognitive MK
• Portfolio All

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Global Clinical Performance Ratings aka End of
Rotation Evaluation

• Most common form of assessment in residency
  programs
• Align questions with key components of the
  competencies
• Most often ratings are inaccurate
• Add behavioral anchors
• Train faculty
• Least effective in predicting a good doctor

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Behavioral Anchors
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Direct Focused Observation The Most Important
Form of Assessment

• Observation of Patient Care Encounter
• Observation of Procedural Skill

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Cognitive Procedure/Case Logs

• Cognitive
• In-training exams
• Multiple Choice Exams
• Procedure/Case Logs

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Portfolio

• A collection of authentic and diverse
  evidencerepresenting what a person has learned
  over timeused to demonstrate competence and
  reflection
• on learning.
• Lewis 2007

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• Portfolio ? File

Reflection
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The Resident as Learner
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Resident Challenges
Sleep and Fatigue
Heavy patient load
Time management
Work-life balance
Time for study / reflection
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Significant Learning
Learning Goals
An Integrated ModelL. Dee Fink, PhDUniversity
of Oklahoma
Teaching and Learning Activities
Feedback Assessment
SITUATIONAL FACTORS
www.byu.edu/fc/pages/design.html
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Holistic Active Learning

• Experience
• Doing, Observing
• Actual, Simulated
• Rich Learning Experiences

• Information Ideas
• Primary Secondary Sources
• Accessing them in class, out of class, online

• Reflective Dialogue
• Minute Papers, Learning Portfolios, Journaling
• About the Subject and/or Learning Process

L. Dee Fink, PhDUniversity of Oklahomawww.byu.ed
u/fc/pages/design.html
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Average Retention Rate after 24 Hours
Focus
Bethel, Maine National Training Laboratories
(1960s)
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How to Enhance Learning?(Entwistle, 1992)

• STUDENT CharacteristicsDEEP APPROACH -
  Previous knowledge of topics - Perceived
  relevance of info - Intrinsic interest in
  subject - Study skillsSURFACE APPROACH -
  Fear of failure - Anxiety - Reliance on
  memorization - Extrinsic motivation

• DEPARTMENT Influences- Matching content to
  previous knowledge- Good teaching-
  Opportunities for individual choice- Study
  skills training support- Short- answer
  MCQs- Heavy workload overloaded curricula-
  Spoon-feeding through handouts- Lack of
  relevance or choice

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Epidemiology of Mislearning(L Shulman)

• Amnesia
• Fantasia
• Inertia

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What is Active Learning?

• Active learning involves students in doing
  things and thinking about the things they are
  doing.
• Charles Bonwell
  www.active-learning-site.com

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Benefits of Active Learning

• When students think actively about class
  material, they process the ideas more thoroughly
  and construct extensive cognitive networks
  connecting new ideas together and linking them to
  what they already know.
  Webb (1989)

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The ACGME Competencies Task Force at SJHMC
Finding the Teamwork in the ACGME
Competencies
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Our Team includes Faculty,
Residents, and Coordinators
in the ACGME Competencies Initiative
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Task Force as Catalyst

• Create an environment that promotes successful
  implementation
• Identify Best Practices in residency programs
• Develop venues, strategies, forms to pilot
• Create a professional development program gt
  train the trainer
• Create interdisciplinary learning experiences

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Resources

• Each other gt Inventory of Resources at SJ
• A Faculty Guide for Implementing the ACGME
  General Competencies at SJHMC (in your
  notebook)- Understand the competencies (p 4)-
  Know the timeline (p 5)- Review the new
  Transition PIF (pp 61-65)- Suggested Best
  Methods for Evaluation (pp 6-8)- Strategies,
  Forms, Web sites

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Handoff Protocols

• How are residents trained on handoffs?
• What types of strategies are included in your
  protocol? (e.g., oral, written, both?)
• Are residents, attendings, faculty, nursing staff
  satisfied with it?
• Do patients have input?
• How does your protocol compare with others?

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Quiz

• 1. True or False.The core competencies are
  relevant only to residency education.

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Quiz

• 2. Which phase of the ACGME Outcome Project
  should programs be involved with at this time?

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Quiz

• 3. Which competency is the anchor or keystone
  of a physicians education?

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Quiz

• 4. What role do the following individuals
  perform in implementing the ACGME competencies
  in GMEa. Faculty?b. Residents?c.
  Coordinators?

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Quiz

• 5. Name the competencies in the following
  domains/categoriesa. Qualityb.
  Behavioralc. Traditional

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Quiz

• 6. What is different about the new Program
  Information Form (PIF) Transition document? .

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Quiz

• 7. Give an example of what programs can do to
  provide an enhanced learning environment for
  residents?

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Quiz

• 8. Which of the core competencies involve QI
  activities.

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Quiz

• 9. How can Coordinators help residency programs
  fulfill the ACGME competency mandate?

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Quiz

• 10. What are the two requirements for Phase III?
  

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Discuss with a Partner

• What is the present situation at your home
  institution? What ideas do you have to apply
  this learning to one or more aspects of
  your home context?
• What is a possible time line for this
  application?

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Gallery of Learning

• What have been your experiences in our session
  today? In what ways have you gained or changed
  in respect to the following
• New knowledge or ways of knowing
• Improvement in
• New or renewed interest in
• Confidence in
• Continued questions about
• The muddiest point

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Tell me and Ill forgetShow me and I may
remember Involve me and Ill understand.

Chinese Proverb
Thank You!