Whitcomb, Michael E. MD
In the lead paper of this issue of Academic Medicine, Carraccio and her colleagues discuss the concept of competency-based education and review how the principles embedded in this concept are being incorporated into the design and conduct of medical education programs. Their paper is particularly timely, since the Accreditation Council for Graduate Medical Education (ACGME) intends to use the accreditation process to make certain that those principles are incorporated into the design and conduct of all graduate medical education (GME) programs. Since program accreditation is a high-stakes event, it is important to give some thought to what this means for those responsible for GME programs. It is particularly important to be clear about the goal of competency-based GME, and what this means for the assessment of residents.
The goal of competency-based GME is quite clear—it is to ensure that residents are competent to practice one of the specialties or subspecialties of medicine before they complete their residency training. In this sense, to be competent means that they are able to provide medical care and/or other professional services in accord with practice standards established by members of the profession and in ways that conform to the expectations of society.
Now, those responsible for the design and conduct of GME programs would surely argue that this goal is already being met. I am sure that they would assert strongly that residents who complete their training programs are competent to enter medical practice, and decades of experience tend to bear them out. Over the years, an overwhelming majority of the physicians entering practice on completion of residency training have proven themselves to be competent practitioners. Does anyone doubt this to be the case?
Accordingly, is there really any need to require GME programs to document for accreditation purposes that the principles embedded in the concept of competency-based education are being incorporated into the design and conduct of those programs? After all, the overwhelming majority of physicians who have completed their residencies are competent practitioners. Isn't that sufficient evidence that the goal of competency-based GME is being met?
Despite the proven competency of program graduates, I do believe that those responsible for the design and conduct of GME programs must do a better job of actually documenting that residents completing training are competent to practice medicine. Why? Given the current focus of attention on medical errors, and concerns about the quality of care in general, I think the public has every right to expect that this will occur. Accordingly, the profession has a responsibility to ensure that it does. Given that, the ACGME is on the right path in requiring GME programs to demonstrate that their residents are competent when they complete their training.
But what kind of documentation should the ACGME require? The real issue here is how programs will be required to document the competence of their graduates. I suggest that the answer to that question must be based on a clear understanding of what is required to be a competent practitioner. To be competent certainly requires that physicians possess the knowledge, skills, and attitudes required for the practice medicine. But as noted above, that is not enough. In addition, physicians must be able to translate the knowledge, skills, and attitudes they possess into a set of complex behaviors that result in the delivery of high-quality medical care.
That being the case, documenting that a resident possesses, at a predetermined level of mastery, the knowledge, skills, and attitudes associated with individual domains of specialty or subspecialty practice is not the same as documenting that the individual is a competent physician. The only way to truly determine the latter is to critically observe the resident caring for patients in a variety of clinical settings and under different clinical circumstances. There is simply no other way to find out whether or not a resident truly exhibits the set of complex behaviors that characterize a competent practitioner.
Accordingly, I see no reason why GME programs should be required to develop and implement new methods for documenting the performances of residents. This approach will almost certainly lead to the “testing” of residents in structured and largely artificial settings. Instead, programs should be required to formalize what is now a largely informal process—that is, the observations that teaching faculty make on a daily basis of the ways that residents perform in providing care to the patients assigned to them.
Thus, those responsible for GME programs should be able to document the competence of residents completing training by ensuring that the program faculty responsible for supervising the care provided by residents understand clearly their obligation to carefully assess the performances of the residents in carrying out their daily activities. To assist the faculty in this effort, they should develop performance guidelines, and establish policies and procedures for how the guidelines should be used. The prevailing practice that exists in most GME programs—the attending physicians' completing an evaluation form at the end of a rotation—is clearly inadequate. Using online reporting systems, the teaching faculty can easily record on a frequent, even daily, basis the observations they make of the performances of residents. For the ACGME's purposes, this kind of documentation should suffice.
Bottom line: I believe that teaching physicians—the program faculty—are quite capable of making judgements as to whether or not the residents they supervise are competent to care for patients under the varied clinical conditions that the residents will encounter when they are in practice. The fact that the overwhelming majority of residents who have entered practice have proven themselves to be competent practitioners is evidence that this is the case, even though the assessment process has been more implicit than explicit. Therefore, what is needed to satisfy the legitimate concerns of the public about the competency of physicians entering practice is not new methods for assessing their competence, but a better system for documenting the faculty's observations.