IMPLICATIONS OF COMPETENCY BASED EDUCATION

DEBORAH E. POWELL, M.D.DEAN OF THE MEDICAL SCHOOL

ASSISTANT VICE PRESIDENT FOR CLINICAL SCIENCESUNIVERSITY OF MINNESOTA

GROUP ON RESIDENT AFFAIRS SPRING MEETING

VANCOUVER, BC

APRIL 18, 2004

THEMES

1. THE CORE COMPETENCIES AND THE FRAMEWORK SURROUNDING THEM

2. COMPETENCIES IN THE CONTEXT OF MEDICAL EDUCATION

3. FAR REACHING IMPLICATIONS

DREYFUS MODEL

STAGES IN HUMAN SKILL ACQUISITION

BASED ON STUDIES OF AIRPLANE PILOTS, CHESS PLAYERS, AUTOMOBILE DRIVERS, AND ADULT LEARNERS OF A SECOND LANGUAGE

DREYFUS MODEL

NOVICE

ADVANCED BEGINNER

COMPETENT

PROFICIENT

EXPERT

DREYFUS MODEL PROGRESSIONS

NOVICE EXPERT

*ABSTRACT PRINCIPLES *PAST CONCRETE EXPERIENCES

*SITUATIONS ARE EQUALLY *SITUATIONS ARE

RELEVANT BITS WHOLES WITH CERTAIN RELEVANT PARTS

*DETACHED OBSERVER *INVOLVED PARTICIPANTS

COMPETENCE

THE QUALITY OR STATE OF BEING FUNCTIONALLY ADEQUATE OR OF HAVING SUFFICIENT KNOWLEDGE, JUDGMENT, SKILL, OR STRENGTH

ACGME GENERAL COMPETENCIES

1. PATIENT CAREPROVIDE COMPASSIONATE, APPROPRIATE & EFFECTIVE PATIENT-FOCUSED (CENTERED) CARE

2. MEDICAL KNOWLEDGEAPPLY KNOWLEDGE OF ESTABLISHED AND EVOLVING BIOMEDICAL, CLINICAL, EPIDEMIOLOGICAL AND SOCIAL-BEHAVIORAL SCIENCES TO PATIENT CARE

3. PRACTICE-BASED LEARNING & IMPROVEMENTEVALUATE PATIENT CARE PRACTICES, APPRAISE AND ASSIMILATE SCIENTIFIC EVIDENCE AND IMPROVE PATIENT CARE PRACTICES

ACGME GENERAL COMPETENCIES CONTINUED

4. INTERPERSONAL & COMMUNICATION SKILLSDEMONSTRATE EFFECTIVE INFORMATION EXCHANGE AND TEAMING WITH PATIENTS, THEIR FAMILIES, AND PROFESSIONAL ASSOCIATES

5. PROFESSIONALISMDEMONSTRATE COMMITMENT TO PROFESSIONAL RESPONSIBILITY, ADHERENCE TO ETHICAL PRINCIPLES, AND SENSITIVITY TO A DIVERSE PATIENT POPULATION

6. SYSTEMS BASED PRACTICEDEVELOP AWARENESS OF AND RESPONSIVENESS TO THE LARGER CONTEXT AND SYSTEM OF HEALTH CARE AND UTILIZE THIS EFFECTIVELY TO PROVIDE CARE OF OPTIMAL VALUE

AMERICAN BOARD OF MEDICAL SPECIALTIES

ENDORSES SIX ACGME COMPETENCIES AS THOSE NEEDED BY PRACTICING PHYSICIANS IN EVERY SPECIALTY

EACH SPECIALTY BOARD WILL REQUIRE RECERTIFICATION OF ITS DIPLOMATES

RECERTIFICATION SHOULD INCLUDE EVALUATIONS OF THE SIX CORE COMPETENCIES

WHAT IF...

WE MADE THE SIX CORE COMPETENCIES THE COMPETENCIES FOR THE EDUCATION OF A PHYSICIAN

?

CONTINUUM OF MEDICAL EDUCATION

COLLEGE UNDERGRADUATEPREREQUISITES MEDICAL

EDUCATION (UME)

GRADUATE MEDICAL EDUCATION (GME)

CONTINUING MEDICAL EDUCATION (CME)

Educational Program ObjectivesUniversity of Minnesota Medical SchoolGraduates of the University of Minnesota Medical School should be able to:

OBJECTIVE OUTCOME MEASURES ACGME ESSENTIAL COMPETENCY

1. Demonstrate mastery of key concepts and principles in the basic sciences and clinical disciplines that are the basis of current and future medical practice.

USMLE Steps 1 and 2 Year 1 and 2 course performance, based on

standardized examinations Clinical rotation performance Feedback from residency directors

Medical Knowledge

2. Demonstrate mastery of key concepts and principles of other sciences and humanities that apply to current and future medical practice, including epidemiology, biostatistics, healthcare delivery and finance, ethics, human behavior, nutrition, preventive medicine, and the cultural contexts of medical care.

USMLE Steps 1 and 2 Course performance (especially in Physician and

Society, Nutrition, and Human Behavior at Twin Cities (TC) campus; Medical Sociology, Medical Epidemiology and biometrics, Family Medicine I, Medical Ethics, Human Behavioral Development and Problems, and Psycho-Social-Spiritual Aspects of Life-Threatening Illness at Duluth (DU) campus

Clinical rotation performance Feedback from residency directors

Medical Knowledge

3. Competently gather and present in oral and written form relevant patient information through the performance of a complete history and physical examination.

Year 2 Objective Structured Clinical Exams (OSCE) Physician and Patient (PAP) course performance at

TC campus, assessed by tutors using global rating forms and observed practical exams

Course performance at DU campus in Applied Anatomy, Clinical Rounds & Clerkship (CR&C), Clinical Pathology Conference, and Integrated Clinical Medicine

Clinical rotation performance

Patient CareInterpersonal and

Communication Skills

Educational Program Objectives Continued

OBJECTIVE OUTCOME MEASURES ACGME ESSENTIAL COMPETENCY

4. Competently establish a doctor-patient relationship that facilitates patients’ abilities to effectively contribute to the decision making and management of their own health maintenance and disease treatment.

Year 2 OSCE and Primary Care Clerkship (PCC) OSCE

PAP course performance at TC campus, assessed by tutors using global rating forms and observed practical exams

Preceptorship and CR&C course performance at DU campus

Clinical rotation performance

Patient Care Interpersonal and

Communication Skills

5. Competently diagnose and manage common medical problems in patients.

PCC OSCE Clinical rotation performance

Medical KnowledgePatient Care

6. Assist in the diagnosis and management of uncommon medical problems; and, through knowing the limits of her/his own knowledge, adequately determine the need for referral.

Clinical rotation performance Documented achievement of procedural skills in the

Competencies Required for Graduation

Medical KnowledgePatient CarePractice-Based

Learning and Improvement

7. Begin to individualize care through integration of knowledge from the basic sciences, clinical disciplines, evidence-based medicine, and population-based medicine with specific information about the patient and patient’s life situation.

Clinical rotation performance Feedback from residency directors

Patient CareMedical KnowledgeInterpersonal and

Communication Skills

Professionalism

QUESTIONS AND CONCERNS

FOR A SPECIFIC SKILL OR OBJECTIVE, WHAT LEVEL OF COMPETENCE IS EXPECTED FOR:

A SECOND YEAR MEDICAL STUDENT?

A FOURTH YEAR MEDICAL STUDENT?

A RESIDENT IN THEIR FIRST YEAR?

A RESIDENT IN THEIR FINAL YEAR?

A SPECIALIST BEING RECERTIFIED?

WHAT IF...

AN INTERNAL MEDICINE CLERKSHIP DIRECTOR AND AN INTERNAL MEDICINE

PROGRAM DIRECTOR PLANNED A CURRICULUM FOR INTERNAL MEDICINE

TRAINING TOGETHER?

WHAT IF...

WE PLANNED FOR THE EDUCATION OF A PHYSICIAN (SURGEON, FAMILY PHYSICIAN, PEDIATRIC OPHTHALMOLOGIST, ETC.) NOT THE EDUCATION OF A MEDICAL STUDENT, A

RESIDENT, A FELLOW

?

WHAT IF...

WE DEVELOPED CRITERIA AND APPROPRIATE ASSESSMENT TOOLS FOR

COMPETENCE

?

QUESTIONS AND CONCERNS

STANDARDS OF COMPETENCE:

ARE THEY INSTITUTION SPECIFIC?

ARE THEY SPECIALTY SPECIFIC?

WHO WILL DEVELOP THEM?

COMPETENCE

WHAT INDIVIDUALS KNOW OR ARE ABLE TO DO IN TERMS OF KNOWLEDGE, SKILLS, ATTITUDE

CAPABILITY

EXTENT TO WHICH INDIVIDUALS CAN ADAPT TO CHANGE, GENERATE NEW KNOWLEDGE, AND

CONTINUE TO IMPROVE THEIR PERFORMANCE

Brit. Med. J. 323:799-803, 2001

WHAT IF...

WE EDUCATED FOR CAPABILITY AS WELL AS COMPETENCE

?

QUESTIONS AND CONCERNS

WILL EMPHASIS ON EDUCATING FOR COMPETENCE AND CAPABILITY CHANGE THE FACULTY/STUDENT RELATIONSHIP?

COMPLEXITY CONCEPTS APPLICABLE TO EDUCATION AND TRAINING

NEITHER THE SYSTEM NOR ITS EXTERNAL ENVIRONMENT ARE, OR EVER WILL BE, CONSTANT

INDIVIDUALS WITHIN A SYSTEM ARE INDEPENDENT AND CREATIVE DECISION MAKERS

UNCERTAINTY AND PARADOX ARE INHERENT WITHIN THE SYSTEM

PROBLEMS THAT CANNOT BE SOLVED CAN NEVERTHELESS BE “MOVED FORWARD”

SMALL CHANGES CAN HAVE BIG EFFECTS

INCREASING COMPLEXITY IN HIGHER EDUCATION

Traditional education and training The future for education and training

Knowledge Knowledge is static, finite, linear, and private

Knowledge is dynamic, open ended, multidimensional, and public

Learning Instructivist model (“facts” are transmitted from teachers to students)

Constructivist model (concepts are acquired, built, and modified through social discourse, incorporated into appropriate schemes, and tested in action)

The teacher “Sage on the stage” “Guide on the side”

Student experience Generally precedes definitive career choices and personal relationships

Lifelong learning means that education converges with (and is influenced by) work, family, and personal development

Assessment Based on reproduction of facts Based on analysis, synthesis, and problem solving

Curriculum development

Historical model (students learn X because it’s always been included

“Outcomes” model (students learn X because employers require it as a competence)

Time and space utilization

Synchronous, mass, single location learning (e.g., lecture theatre, laboratory

Asynchronous, individualized, with networked learning support

Evaluation Teacher-focused (“what is being provided?”)

Learner-focused (“what are the learners’ needs and are they being met?”)

WHAT IF...

WE TOOK A NEW LOOK AT THE EDUCATION OF A PHYSICIAN

?

“IF THE UNITED STATES IS TO RETAIN ITS LEADERSHIP IN MEDICINE, AN UNDERSTANDING OF THE HISTORY OF AMERICAN MEDICAL EDUCATION DURING THE PAST CENTURY REVEALS THE PRINCIPLES THAT MUST BE FOLLOWED. THE KEY LIES IN RESTORING THE TATTERED SOCIAL CONTRACT BETWEEN MEDICINE AND SOCIETY. THE MEDICAL PROFESSION MUST REMEMBER THAT IT EXISTS TO SERVE; SOCIETY MUST REMEMBER THAT IT WILL NOT HAVE GOOD HEALTH CARE UNLESS IT PROVIDES THE NEEDED FINANCIAL AND MORAL SUPPORT. FORTUNATELY FOR THE UNITED STATES, THE OPPORTUNITY TO RETAIN THE WORLD’S PREMIER SYSTEM OF MEDICAL EDUCATION, RESEARCH, AND PRACTICE STILL EXISTS. THE TIME LEFT TO RECAPTURE A CONSTRUCTIVE COURSE OF ACTION IS SHRINKING, BUT THERE ARE STILL SUFFICIENT OPPORTUNITIES FOR VISIONARIES TO DREAM AND LEADERS TO ACT.”

- KENNETH LUDMERER

The EndDownload the post test and return

the completed test to Dr. Sandra Oliver

Post test one

1. Which of the following is not found in the Dreyfus model?1. NOVICE

2. SUPERIOR TRAINEE

3. COMPETENT

4. PROFICIENT

5. EXPERT

Post Test Two

2. ACGME Competencies include all of the following except:1. Provide patient focused care2. Personal communication skills3. Practice based learning and improvement4. Systems based practice

Post Test Three

Which of the following defines competence?1. What individuals know or are able to do in terms of

knowledge, skills, attitude.

2. Extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance

3. The ability of individuals to proceed or progress toward a goal.

4. The disciplined ability and willingness to make objective judgments on the basis of well supported reasons as a guide to belief and action, and to monitor one’s thinking while doing so.