Sklar, David P. MD
A few days ago, I picked up a chart in the ER to read the nurse’s triage note. Over the years, I have encountered notes that piqued my interest, due to an unusual symptom or an odd name, or provided an early clue—such as abnormal vital signs—to a serious problem. For this patient, the note said, “Woman on hospice. Family called ambulance because cough is not getting better.” There was a resident with me, and I asked her if she had noticed anything odd about the triage note.
“Well, the patient is an 87-year-old woman and she is on hospice. That’s pretty normal. But if she is on hospice, aren’t they supposed to call the hospice nurse instead of the ambulance?” said theresident.
“Exactly,” I said, “but sometimes families panic when the patient is getting worse. We will see what the family says.” I was excited about the prospect of a case that might allow us to explore certain competency domains outside of the usual areas of patient care and medical knowledge. This patient could introduce the resident to the subtleties of hospice rules, which would involve systems-based practice, and our discussion would probably require skillful communications and interpersonal relations. If we could develop learning goals, we might even address practice-based learning and improvement.
I have tried to be a dutiful advocate of the competencies ever since they were first introduced by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties in 19991 because I believe they encourage residents to move beyond their usual comfort levels into areas such as ethics, economics, or social services that may be as important to a patient as the medical treatments. But without some preparation, it is not easy to divert attention from the medical problem at hand to have an informed discussion about complex payment or social issues. More than 13 years have passed since the introduction of the competencies, yet progress toward their full integration into medical education has been slow.
In this month’s Academic Medicine we have two articles2,3 that offer some optimism that we may now be on the cusp of broad implementation of competency-based education, not only in graduate medical education but in other phases of medical education and in other health professions. Carraccio and Englander2 update a previous discussion of competencies4 published in this journal 11 years ago and describe some of the successes, challenges, and next steps for competency initiatives. They suggest that while identification and description of the competencies have moved forward, assessment has been a challenge, particularly in the areas outside of patient care and medical knowledge. Direct observation holds great promise but must be done by motivated faculty who have the expertise, experience, and tools to provide meaningful assessments. The development of milestones and “entrustable professional activities” also hold promise for providing “a holistic perspective on learner assessment.” The authors conclude with their vision of what successful adoption of competency-based medical education will look like.
In a related article, Englander and colleagues3 describe domains of competence for health professions and provide a reference list of competencies for physicians based on their review of different health professions’ efforts to define their competencies. They include a domain of interprofessional collaboration, highlighting the importance of improving the function of interprofessional teams, and maintain that establishing a common language and understanding of competencies will help in the implementation of competency-based education. Taken together, these two articles make clear that medical education has moved away from a strict, time-bound training curriculum to a more fluid competency approach that will also require a broader perspective on which areas should be mastered before completion of training.
As I prepared to visit with our patient, I tried to keep in mind how I might frame my comments to the resident to assist in her evolving expertise in the competencies. When we entered the room, there were three people: the patient, an elderly woman with a gaunt but peaceful face, sleeping quietly; her husband, sitting in a chair at the head of the bed; and the daughter, sitting at the foot of the bed. The patient did not seem to be in any pain or in any respiratory difficulty and mumbled incomprehensibly when we asked how she was feeling. I was surprised that everyone seemed so calm. The husband had a ruddy complexion and spoke in sentence fragments. In between each fragment there was a long pause—like the silence after depositing coins in a soda dispenser and waiting for the “clunk” as the can of soda drops. He took a deep breath between fragments, stared at us, and said, “No good … has a cough … over a week … not getting better … lazy nurse … not eating … called 911.” The resident obtained this history by asking the husband what had happened and why they had brought his wife to the hospital. The woman’s daughter sat quietly listening, twisting her long dark hair between her fingers, and occasionally nodded to demonstrate her agreement.
When the resident was finished, I asked if there was anything else she wanted to know. She paused for a moment, realizing that there must have been something I wanted her to ask, and then said, “Mr. S, why is your wife in hospice?”
“The nurses … trying to get her in a nursing home … maybe three weeks … maybe three years … don’t know … little strokes … lots of little strokes … maybe another one.”
I began to wonder whether he was confused and was the one with the strokes, affecting his speech and thought patterns. I worried about the resident trying to find her way through this muddle of information. But she continued resolutely on to question the daughter: “Ma’am, do you know why your mother is on hospice? Usually hospice is for people who … are … suffering.” I nodded in approval of this neutral choice of words that did not assume anything about what the family understood.
“She’s suffering. We all are. It was those Home Health people who suggested it, just until we could get her into a nursing home to pay for the nurse. I guess now that we come to the hospital, they can’t come to the house anymore. That’s what they said.”
We gradually sorted out the pieces of the story: The elderly woman had slowly been losing her memory and was now falling and not eating, and was sleeping during the day but awake at night, wandering around the house and coughing, keeping everyone awake. The woman’s doctor had ordered a few tests and explained that there was nothing more to be done and that she needed a nursing home. But that would take time, and in the meantime, he recommended home health care nurses. The nurses had suggested the hospice program, which would give her six months of paid nursing coverage. Then the woman started to get worse and was coughing and falling down, and the coughing had become more frequent. The hospice nurse had nothing to offer except cough syrup or morphine. The family expected that more should be done. That was what prompted the call to 911.
We ordered tests and X-rays and ultimately diagnosed a urinary tract infection. As I sat with the resident later to discuss the case, I realized that from a purely scientific perspective the case was rather simple. The woman had a urinary tract infection, and antibiotics would likely cure it. We could discuss the etiology of urinary tract infections in the elderly and the contribution of the infection to the woman’s lethargy, falling, and dementia. Perhaps we could discuss antibiotic choice and dosage. These linkages of scientific concepts to medical care had been the foundation of the Flexner recommendations for improving medical education and had helped move medicine into the modern era.4 But these were not the issues that would probably be most important for this patient. There were other questions: What are the rules for hospice? Did this woman meet the criteria? Who certified that she met the criteria? What was the history of the hospice program and funding?
There was another set of questions to consider also: What was the woman’s living condition? Who was caring for her? Did the husband have the capacity and resources to care for her? What was the role of the daughter? Would her mother be better off in a nursing home? Who would pay for the nursing home? How do you get into a nursing home?
Then there was even another set of questions: Why had our communications with the patient and family been so difficult? How confident was I that we had obtained the most critical information? What other sources of information did we need?
Yet more questions: Would it be best to admit the woman to the hospital to sort out the social issues and begin the treatment and perhaps help with nursing home placement? Would the woman meet admission criteria on the basis of our diagnosis of urinary tract infection? Would the hospital and medical staff get paid? Would the internal medicine team balk at our “soft, social admit” and tell us that other, sicker patients needed the bed? What if they refused to admit her? How would we convince them to admit her?
All these questions covered several of the core competencies that a resident should understand and master before graduation, but they were all mixed together. I believe this case illustrates a basic quandary of medical education. Some of our most difficult and important cases do not come to us neatly dissected into categories. They are a tangle of social, medical, economic, legal, and sociological problems, and many doctors would probably say that other members of the health care team ought to be responsible for addressing them. Often, doctors do not have the time or expertise in these areas. And yet this case would not be solvable with a narrow, bioscientific model of knowledge. In addition, familiarity with health policy and social services resources, negotiating skills, understanding of communications, and the ability to integrate them would be required to solve this patient’s problems. This is precisely why the development of competencies that take us beyond medical knowledge and patient care has been critical. But thus far we have not demonstrated an ability to assess whether our residents have mastered those competencies. A few years ago, Lurie et al5 analyzed the published literature on competency assessment and suggested that we are not yet able to assess the competencies in a meaningful way with our current tools; I believe this is still true. They further suggested that the competencies might work better to stimulate curriculum expansion than to measure and assess residents’ performance, since what we are measuring is not clear, and our measures are neither valid nor reliable.
I am hopeful that as each specialty develops milestones, we may create better tools for assessment of all competencies. However, even with better tools, there are at least three steps we will still need to take to fully implement competency education.
First, clinical faculty will have to become engaged and convinced of the value of the competencies. At this point I do not believe they have completely bought into that value. Why is that? Could it be because they do not feel comfortableinthe areas of health systems, communications, professionalism, formal assessment, and other areas that are not strictly biomedical? Until our clinical faculty believe that all competencies are important and should be assessed, the residents will think of the competencies as this week’s spelling words to be memorized for the test and then quicklyforgotten.
Second, the evaluation of competencies depends on a faculty–student relationship based on adequate time and commitment. A previous editor of this journal, Dr. Michael Whitcomb,6 emphasized the importance of faculty observation of residents’ clinical care as the key to competency evaluation, shortly after the competency framework was published. The smaller residencies have the advantage of greater contact between residents and faculty; in particular, surgical specialties provide the close supervision of operative care that offers opportunities for evaluation that may not typically exist in internal medicine or pediatrics. We will need to look carefully at how to encourage better resident–faculty supervision and education in our larger nonsurgical programs. If we can create a conducive environment for faculty–student–patient interactions, the evaluation tools and skills best adapted to the educational setting may become clear.
Third, we must recognize how the competencies are integrated and teach them and evaluate them as bundles rather than as isolated attributes. A case such as the one I described above demonstrates how the competencies interact when caring for actual patients. A focus on complex cases such as that one will ensure that our patients and their problems are at the center of educational programs rather than peripheral to discussions about a disease or a procedure. An emphasis on the full spectrum of competencies can complement an emphasis on quality and safety that will honor our commitment to our students, our patients, and the public.