IMPLICATIONS OF COMPETENCY BASED EDUCATION

DEBORAH E. POWELL, M.D.

DEAN OF THE MEDICAL SCHOOL ASSISTANT VICE PRESIDENT FOR CLINICAL SCIENCES UNIVERSITY 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 *ABSTRACT PRINCIPLES *SITUATIONS ARE EQUALLY RELEVANT BITS *DETACHED OBSERVER EXPERT *PAST CONCRETE EXPERIENCES *SITUATIONS ARE WHOLES WITH CERTAIN RELEVANT PARTS *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 CARE PROVIDE COMPASSIONATE, APPROPRIATE & EFFECTIVE PATIENT-FOCUSED (CENTERED) CARE 2. MEDICAL KNOWLEDGE APPLY KNOWLEDGE OF ESTABLISHED AND EVOLVING BIOMEDICAL, CLINICAL, EPIDEMIOLOGICAL AND SOCIAL-BEHAVIORAL SCIENCES TO PATIENT CARE 3. PRACTICE-BASED LEARNING & IMPROVEMENT EVALUATE PATIENT CARE PRACTICES, APPRAISE AND ASSIMILATE SCIENTIFIC EVIDENCE AND IMPROVE PATIENT CARE PRACTICES

ACGME GENERAL COMPETENCIES

CONTINUED

4. INTERPERSONAL & COMMUNICATION SKILLS DEMONSTRATE EFFECTIVE INFORMATION EXCHANGE AND TEAMING WITH PATIENTS, THEIR FAMILIES, AND PROFESSIONAL ASSOCIATES 5. PROFESSIONALISM DEMONSTRATE COMMITMENT TO PROFESSIONAL RESPONSIBILITY, ADHERENCE TO ETHICAL PRINCIPLES, AND SENSITIVITY TO A DIVERSE PATIENT POPULATION 6. SYSTEMS BASED PRACTICE DEVELOP 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 PREREQUISITES

UNDERGRADUATE MEDICAL EDUCATION (UME) GRADUATE MEDICAL EDUCATION (GME) CONTINUING MEDICAL EDUCATION (CME)

Educational Program Objectives University of Minnesota Medical School

Graduates of the University of Minnesota Medical School should be able to:

OBJECTIVE OUTCOME MEASURES

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.

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. 3. Competently gather and present in oral and written form relevant patient information through the performance of a complete history and physical examination.            USMLE Steps 1 and 2 Year 1 and 2 course performance, based on standardized examinations Clinical rotation performance Feedback from residency directors  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 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

ACGME ESSENTIAL COMPETENCY

Medical Knowledge Medical Knowledge Patient Care Interpersonal and Communication Skills

Educational Program Objectives Continued

OBJECTIVE 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.

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

   OUTCOME MEASURES    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 PCC OSCE Clinical rotation performance ACGME ESSENTIAL COMPETENCY Patient Care Interpersonal and Communication Skills Medical Knowledge Patient Care   Clinical rotation performance Documented achievement of procedural skills in the Competencies Required for Graduation   Clinical rotation performance Feedback from residency directors Medical Knowledge Patient Care Practice-Based Learning and Improvement Patient Care Medical Knowledge Interpersonal 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 Learning The teacher Student experience “Sage on the stage” Generally precedes definitive career choices and personal relationships Assessment Curriculum development Knowledge is static, finite, linear, and private Instructivist model (“facts” are transmitted from teachers to students) Based on reproduction of facts Historical model (students learn X because it’s always been included Knowledge is dynamic, open ended, multidimensional, and public Constructivist model (concepts are acquired, built, and modified through social discourse, incorporated into appropriate schemes, and tested in action) “Guide on the side” Lifelong learning means that education converges with (and is influenced by) work, family, and personal development Based on analysis, synthesis, and problem solving “Outcomes” model (students learn X because employers require it as a competence) Time and space utilization Evaluation Synchronous, mass, single location learning (e.g., lecture theatre, laboratory Asynchronous, individualized, with networked learning support 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 End Download 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 care 2. Personal communication skills 3. Practice based learning and improvement 4. Systems based practice

Post Test Three

Which of the following defines competence?

1.

2.

3.

4.

What individuals know or are able to do in terms of knowledge, skills, attitude.

Extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance The ability of individuals to proceed or progress toward a goal. 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.