Teaching residents the core competencies, particularly professionalism and interpersonal/communication skills, may be challenging.1,2 However, our experience as residency program directors suggested that residents matriculating into the St. Luke's–Roosevelt anesthesiology residency program had little knowledge of any physician competencies and had shown ambivalence toward them. Accordingly, we recently altered our interview process to include both a questionnaire surveying the applicant's knowledge of the Accreditation Council for Graduate Medical Education (ACGME) core physician competencies and also a thorough discussion of them as a part of our interview day presentation. Thus, no applicant would leave our interview day without an awareness of his or her degree of knowledge of the ACGME competencies and an understanding that if that individual chose our program, he or she would need to develop these competencies. Our primary purposes were to emphasize our department's commitment to competency-based graduate medical education in anesthesiology and to ascertain whether our applicants were aware of the core competencies required of a physician. The following is a retrospective report of our findings from the first use of the survey in our application process.
During the residency interview process in the fall of 2008, one or the other of the three program directors (J.W., J.G., or C.R.) asked 193 fourth-year interviewed U.S. MD-degree medical students applying to the St. Luke's–Roosevelt Hospital Center anesthesiology program to complete a one-item questionnaire examining their knowledge of the core competencies mandated by the ACGME. The application tool asked applicants to “identify the six core physician competencies.” The reasons for the exercise, as well as the directions for completing the form, were delivered in all cases by one of the three aforementioned program directors. According to the instructions, if applicants had no understanding of what was meant by the term core physician competency, had never heard of the core competencies, or could not remember the core competencies, they were to indicate on their form “DK” (don't know). Applicants were encouraged to list what they perceived as the core competencies of a physician. After applicants had answered the question, all forms were collected and reviewed with the applicants. A group discussion ensued in which core physician competencies were delineated, and a brief presentation was given on how the competencies applied to anesthesiology. Applicants were instructed that the department would expect matriculating residents to continually focus on the competencies during their training. At the conclusion of the interview season, the survey forms were retrospectively and anonymously analyzed to provide a profile of the department's applicant pool. The institutional review board approved this retrospective, observational report.
A total of 193 U.S. MD-degree medical students interviewed by our program completed the questionnaire. Seventy-six students (39%) did not have any knowledge of any of the physician competencies. Table 1 presents the number of applicants who were able to correctly identify one or more of the six ACGME competencies: medical knowledge, patient care, professionalism, communications, systems-based practice, and practice-based learning and improvement. The competencies most frequently identified were professionalism (39%) and medical knowledge (33%), whereas the remaining four competencies were all about equal in identification (range 10%–15%). Table 1 also shows the number of students indicating desirable physician attributes, such as empathy, honesty, hard work, compassion, safe practice, teamwork, ethical practice, trust, research, and cultural sensitivity, that they believed to be, and identified as, ACGME physician core competencies. Table 1 likewise indicates the number of ACGME core competencies identified per applicant. Fifty-five students (28%) were able to identify at least one competency, but only three (2%) were able to identify all six correctly.
The U.S. MD-degree medical students whom we queried had limited knowledge of the ACGME core competencies that they would need to master during anesthesiology residency training. Whereas many identified attributes desirable of physicians, such as empathy and compassion, an overwhelming majority were ignorant of the core ACGME physician competencies.
Although there is much overlap between the Association of American Medical Colleges' medical student learning objectives and the ACGME's core competencies, they are not identical. Additionally, medical schools can determine their own individualized, competency-based curricula.3,4 Consequently, when medical students enter residency training, they may have been previously exposed to a variety of competency-based educational programs or instructed in a myriad of desirable physician traits without being directly taught the ACGME competencies that will be the basis of their postgraduate training and lifelong learning.1,2 This lack of knowledge may prove challenging for program directors as they attempt to focus residents' attention toward mastery of the six prescribed ACGME competencies. For instance, among anesthesiology faculty and residents, professionalism often has been confused with a list of desirable behaviors that are fostered via implicit teaching rather than via explicit education through discussion and seminars.2
A possible limitation of our report is that it is essentially an isolated observation of one department's attempt to select “competency-aware” candidates for residency in anesthesiology. It is possible that medical students applying to other programs in anesthesiology, or to other disciplines, might have a greater degree of knowledge regarding the core competencies. However, we believe that other programs are facing similar challenges in teaching professionalism and systems-based practice.1,2 Nonetheless, the issue of the applicability of our findings would need to be examined through a prospective study. It is also possible that preresidency knowledge of the core competencies will not be particularly useful in helping residents adopt the core competencies in their residency or postgraduate lifelong learning. Likewise, it is possible that our interview pool of U.S. MD-degree medical students was distributed in such a manner that our applicants were disproportionately from schools that emphasized their own individualized competencies as opposed to those mandated by the ACGME.
Nonetheless, it is troubling that 39% of the members of our applicant pool were unaware of the core physician competencies. Our observations suggest that U.S. MD-degree students come to their residency interviews in anesthesiology with a very limited awareness of the competencies that they will need to successfully master the discipline of anesthesiology using a competency-based curriculum. Moreover, the wide variety of respondents' identifications of desirable physician traits separate from the established core competencies suggests that medical students are being instructed with established educational outcomes in mind but in a manner individualized by the various accredited medical colleges. Additional investigations might examine the degree of competency awareness in those schools that use the ACGME competencies as a part of their educational objectives and evaluation processes versus those that use individualized evaluative systems. And no matter what such investigations may find, will medical students more familiar with the ACGME competencies be more accepting of them on entry into residency training than those educated by schools with more individualized competency agendas?
What is clear from our application process is that far too many U.S. MD-degree medical students applying to our anesthesiology program were not sufficiently well versed in the competencies required of a physician. If these observations more broadly represent the state of U.S. MD-degree medical students, medical educators and program directors should consider how competency awareness can be increased in students so that all students are familiar with competency-based residency training when they enter their residencies.
St. Luke's–Roosevelt Hospital Center institutional review board.
1 Tetzlaff J. Assessment of competency in anesthesiology. Anesthesiology. 2007;106:812–825.
2 Gaiser R. The teaching of professionalism during residency: Why it is failing and a suggestion to improve its success. Anesth Analg. 2009;108:948–954.
3 Litzelman DK, Cottingham AH. The new formal competency-based curriculum and informal curriculum at Indiana University School of Medicine: Overview and five-year analysis. Acad Med. 2007;82:410–421.
4 Nierenberg DW, Eliassen MS, McAllister SB, et al. A Web-based system for students to document their experiences within six core competency domains during all clinical clerkships. Acad Med. 2007;82:51–73.