Response to the 2012 Question of the Year
Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice, Evidence-Based Practice, Practice-Based Learning and Improvement, Interpersonal and Communication Skills. Since 1999, every faculty member and resident has known that these are the desired competencies of our graduates and the standard to which our residents will be held. Similarly, these competencies, or small variations of them, have also become the basis for changes in undergraduate medical education. Competency-based education is now the norm for nearly all efforts at curricular reform.
The rationale for adopting this method of assessing the success of our residents, students, and educational programs is to move away from merely examining the processes used in education (e.g., the number of conferences or hours dedicated to professionalism education) and to look for demonstrable outcomes of the entire educational experience. Ostensibly, this will lessen some of the burden of reporting on each process and allow schools, hospitals, and programs more individuality and creativity in creating competent physicians. It also changes the system of accountability so that learners and their educational programs are now required to demonstrate competence in these areas and not just report the successful completion of a certain number of months of training or attendance at conferences.
With few exceptions, these changes have been accepted as necessary and good. The recently announced changes to the GME accreditation system are designed to further improve this system.1 It will become a more continuous reporting system of the accomplishment of predetermined milestones for residents as they pass through residency. It is proposed that programs that can show the consistent accomplishment of these milestones will be free to develop more innovative curricular mechanisms.
The problem is that our residents and, by extension, our medical students, are not always being trained in hospitals, health systems, and medical schools that demonstrate these same accomplished competencies. How can we expect residents to learn how to work within a systems-based practice when so many of the teaching health systems are severely broken? Is it possible for residents to demonstrate the professionalism competency when many of their role models do not and there is no requirement for faculty competency in this area? Even something as straightforward as evidenced-based practice becomes difficult when faculty may not be as facile at searching the literature as are the residents themselves, or as dedicated to critically examining relevant studies as faculty should be. Asking residents to demonstrate competency in areas in which the institution or faculty are incompetent is analogous to asking persons living in a dictatorship to demonstrate competency as free and engaged citizens in a democracy. Residents probably will be able to describe the competencies, and may even achieve a measurable proficiency in those areas, but they won’t live them every day, and won’t work in a environment that makes these competencies part and parcel of the clinical and educational experience. Thus, it is hard to believe that they will be able to fully incorporate these competencies into their careers.
While no one would advocate a return to the process-driven accreditation schemes that were used before, it is time to apply the same competencies that we require of our residents to our residencies, our hospitals, and our health systems. Are the hospitals that our residents train in demonstrating competency in delivering the highest levels of patient care and creating and maintaining an integrated system-based practice? Are faculty employing the best available evidence, able to find and critically appraise the literature, and demonstrating a competent level of professionalism? There are mechanisms for measuring all of these, but it would require a scrutiny of ourselves and our systems that we might not enjoy.
To ensure that those who work and learn in medical schools and teaching hospitals can develop to their full potential, outcomes need to be clearly defined and measured, but not just for our residents and students. Our faculty, residencies, teaching hospitals, and medical schools need to have demonstrable evidence that they are all meeting the same competencies.
1. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—Rationale and benefits. N Engl J Med. 2012;11:1051–1056