Whitcomb, Michael E. MD
Most readers of this journal know that several years ago the Accreditation Council for Graduate Medical Education (ACGME) sought to bring an educational outcomes focus to the design and conduct of graduate medical education (GME) programs. The council adopted a set of six core competencies as the framework for that initiative. And I suspect many also know that the American Board of Medical Specialties (ABMS) has adopted the ACGME core competency construct as the guide member boards must use in developing the Maintenance of Certification (MOC) programs they will conduct in the near future. The ABMS decision to take this approach makes sense, since the framework for developing requirements for maintenance of certification should relate, at least in a general way, to the requirements that must be met for achieving initial certification—that is, the successful completion of an ACGME-accredited residency program.
Since the core competency construct now has meaning across the continuum of graduate and continuing medical education, it is not surprising that some would wonder why medical schools have not embraced it as the framework for organizing the education of medical students. I have been asked on more than one occasion why the AAMC has not been more active in stimulating our member medical schools to “get with it,” and why the Liaison Committee for Medical Education (LCME) has not adopted a requirement making this a “must” for accreditation purposes. Given that, I decided to share my perspective on this issue.
To begin, let me state once again that I believe that the principles inherent in a competency-based approach should guide the design and conduct of medical education programs, including those in medical schools. The Institute of Medicine has emphasized the importance of this approach in reforming health professions education.1
It is important to be clear, however, about the basic educational principles that must be followed in implementing a competency-based medical education program. Simply identifying domains in which a physician must be “competent” (the so-called core competencies) is not sufficient. As Carraccio and her colleagues2 pointed out recently, the real challenge for those involved in designing competency-based educational programs is to delineate the knowledge, skills, and attitudes that learners must acquire to be able to perform within each domain at a predetermined level and to recognize that the expected level of performance within each domain will vary depending on the learner's stage of education and the specialty he or she is learning. For example, one would not expect medical students to perform at the same level as residents, nor would one expect internal medicine residents to perform at the same level as surgical residents, at least in some domains. So, the core competency construct is useful in guiding the design of educational programs only if it leads first to the development of specific learning objectives for each core competency—that is, the knowledge, skills, and attitudes the learners enrolled in the programs are expected to achieve.
The ACGME recognized this when it integrated the core competency approach into its accreditation procedures. Each of the ACGME Residency Review Committees (RRCs) was charged to develop discipline-specific learning objectives for the six core competencies. Once those have been established, individual programs will have to assess their residents in ways acceptable to the ACGME to ensure that the residents have achieved the expected outcomes. Because the knowledge, skills, and attitudes needed for initial certification and maintenance of certification in any given specialty are so similar, the learning objectives established by the RRCs may well be useful for designing MOC programs in each specialty. But because medical students and residents are at quite different stages in the process of learning to become a doctor, few, if any, of those learning objectives will be appropriate for designing medical students’ education programs.
So where does that leave those responsible for the education of medical students? Well, it simply means that medical school deans and faculties must do what the ACGME RRCs have been charged to do—that is, they must determine the learning objectives that are appropriate for guiding the education of medical students. Yet I suspect one of the reasons why the undergraduate medical education community has not rushed to embrace the ACGME core competencies is that medical schools had begun to develop learning objectives for their educational programs before the ACGME set forth the core competency construct. The LCME has had a standard requiring medical schools to develop learning objectives for their programs leading to the MD degree for some time, and the AAMC's Medical School Objectives Project (MSOP)—a project that began about eight years ago—was established to assist the schools in accomplishing that. So while the ACGME core competency construct has proven to be useful in promoting a competency-based approach for designing and conducting GME and MOC programs, it was not needed to promote the development of learning objectives for undergraduate medical education programs.
Given that, does the ACGME core competency construct have any meaning for medical school deans and faculties as they strive to enhance the education of their students? It seems to me that since the core competencies are being used across the continuum of undergraduate and continuing medical education, it makes sense to use them in designing the programs that prepare medical students for the next stage of the medical education continuum. In fact, several analyses have shown that it is quite easy to align the learning objectives set forth in the MSOP Report I with the six core competencies adopted by the ACGME. The approach that Brown Medical School has taken in developing and implementing a competency-based curriculum is one model that other schools might adopt.3 To the extent that medical schools have not yet developed learning objectives for their programs, they would certainly find it useful to organize such efforts using the ACGME core competency construct.
In closing, I want to reemphasize a point I made in a previous editorial. While the core competency construct has merit in ensuring that GME programs will achieve certain educational outcomes, it is important to understand its limitations. Before allowing residents to complete their training, program directors and faculties must ensure to their satisfaction that the residents are capable of performing the complex, integrative tasks that are required to provide high-quality patient care, and that they can perform those tasks in the various venues where they will encounter patients. This is the real measure of clinical competence. While there is value in documenting that residents have achieved a predetermined level of performance in a number of different domains (the core competencies), that is not in and of itself sufficient to decide that a resident is ready to enter practice. The true clinical competence of residents can only be determined by observing them providing patient care during the course of their training. Multiple-choice examinations and other assessment tools that focus on individual domains of practice are not enough!
Michael E. Whitcomb, MD
1.Greiner AC, Knebel E (eds). Institute of Medicine: Committee on the Health Professions Education Summit. Health Professions Education. A Bridge to Quality. Washington, DC: National Academy Press, 2003.
2.Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: from Flexner to competencies. Acad Med. 2002;77:361–7.
3.Smith SR, Dollase RH, Boss JA. Assessing students’ performances in a competency-based curriculum. Acad Med. 2003;78:97–107.