A tidal wave of public concern for the quality of health care has engulfed our profession. Both government and private sectors are now intimately involved in judgment of what previously was solely in the hands of health professionals. In part, the public assesses the quality of health care on the basis of the adequacy of professional service outcomes. In turn, the sufficiency of these outcomes has become linked to the attribute of practitioner “competence.” The centrality of competence has expanded; now, the effectiveness of medical education programs is being ascertained by their ability to develop a repertoire of specific competencies. Reflecting this focus, the former educational emphasis on knowledge acquisition is being replaced by competence development. No longer is “What does the practitioner know?” the focal issue; rather, the crucial question is, “What can the physician effectively do? ”
Recognizing these realities, several Preventive Medicine (PM) educational standard setting and certification bodies actively redefined this specialty in terms of the Competencies qualified practitioners are expected to possess. In turn, this list of masteries determined the educational Requirements to be met by each residency program. This approach to describing residency training requirements in terms of competencies represented a marked change. Until now, training program requirements 1 simply listed cognate knowledge that each were expected to provide. Absent such discrete enumeration of required bodies of knowledge, those responsible for the design of PM curriculum content now must reexamine their programs’ educational offerings. They face the challenge of ensuring that their curriculum provides an adequate knowledge base on which these pivotal competencies can be developed and built.
In response to the demands of this educational reorientation, we revisited the curricular elements of this institution’s 44-year-old Occupational Medicine (OM) residency, especially with reference to the knowledge acquisition processes. The issues of curricular design, constraints, and practicalities that emerged in the course of this review are the main subjects of this editorial.
Historical Background: Knowledge and Competencies
The following PM, OM, and Environmental and Occupational Medicine (EOM) organizations’ proposals arise from each of their responsibilities in the US undergraduate and graduate medical education and certification arena. Among the earliest of these efforts was the 1987 publication of “An Inventory of Knowledge and Skills Relating to Disease Prevention and Health Promotion,”2 by the Association of Teachers of Preventive Medicine, subsequently revised in 1994. 3 It must be recognized that these were primarily developed for use in undergraduate medical settings; they specifically dealt with the basic elements and concepts of PM in general.
Concomitantly, as interest evolved to a focus on competency as the primary measure of educational adequacy. The American College of Preventive Medicine, in conjunction with the Health Resources and Services Administration (HRSA), formulated 31 Competencies * expected of all PM specialists. In this 1993 report, HRSA suggested that other PM specialty organizations elaborate the specific Competencies expected in each of the component specialities under the American Board of Preventive Medicine.
Consequently, the American College of Occupational and Environmental Medicine 5 (ACOEM) provided detailed expositions of 14 clinical and 11 OM-specific Competencies expected of EOM specialists. They observed that one type of practitioner, the “generalist,” would possess largely clinical competencies and mainly provide clinical services to “… occupational clients.” Another category, ie, “specialists,” by virtue of their graduate OM specialty training, would address comprehensive, population-based health needs and environmental concerns of workers and communities. † They also concluded that various arrays and depths of competencies would be found among the total body of EOM practitioners.
Reflecting this educational requirement shift toward competency development, in 1998 the Residency Review Committee for Preventive Medicine of the Accreditation Council for Graduate Medical Education revised their residency program “Requirements” document. A draft of new PM Residency Training Requirements was formulated in terms of the competencies expected to be developed among PM residents; later these were distributed to residency directors for comments. 6 The rationale for this shift of emphasis to competency as a measure of the adequacy of educational programs is well described by the HRSA Report. The competencies as formulated in all of the foregoing reports seem to be relevant and well-reasoned. However, in the course of the attempts to devise such a competence-driven instructional program, several problems and issues have emerged, precipitated by curricular reality constraints and contemporary OM practice characteristics
I believe that these analyses reflect a long-term overview of the graduate education scene based on: (1) a quarter-century of full-time graduate OM educational activity, which was (2) interrupted in mid-course by 15 years of OM practice at a significant level of responsibility; (3) more than 15 years of experience as a Specialist Site-Visitor for the Residency Review Committee of the Accreditation Council for Graduate Medicine Education that provided a firsthand opportunity to critically observe “troubled” OM residencies; and (4) a 9-year tenure as Trustee and Vice-Chair for Occupational Medicine on the American Board of Preventive Medicine. (These three terms provided a unique opportunity to observe intimately the impact of the then extant alternative educational pathways upon examination performance.) Because of these long-term responsibilities in graduate medical educational programming and curricular development, this review focuses on the Knowledge Transfer component of residency curricular development. In addition, this reexamination has raised other questions and observations regarding the development of competence and the inculcation of professionalism by the educational process.
The Education of Professionals: A Brief Summary of the Three-Step Process
This process can be summarized as a three-step sequence consisting of the following phases. Phase 1: Knowledge Transfer, is the point at which bodies of relevant information are presented to students for their acquisition and comprehension. This, in essence, is training, the initial step in the education process. This phase presumes little or no ability and, at best, few opportunities to assemble and apply information gained. But as students begin to apply these large stores of knowledge during this transfer phase, they come to appreciate the extent of their knowledge needs. In brief, the outcome of the activities in this phase should lead to enhancement of that which the student knows.
In Phase 2: Competence Formulation and Development, the beginnings of competency develop through assembling multiple, appropriate, and relevant bodies of knowledge in a coherent, organized fashion, sufficient to effectively design, implement, and manage clearly defined and measurable goal-oriented outcomes. In summary, this phase is directed toward the development of that which an individual can do.
Ultimately, with the passage of time evolves Phase 3: Professional Inculcation, which provides an all-enveloping ethos that will govern and direct subsequent behavior. In effect, this is the beginning of a final, yet continuing, critical and most problematic step in the education of a professional.
It is upon viewing the multiple steps and elements of this process that a clarifying perspective emerges for the terms training, learning, and, finally, education.
The Knowledge Acquisition Phase: The Issue of Breadth and Depth of Knowledge Transfer
The educators’ initial challenge is to design curricula that will provide a sound knowledge base on which competencies may be built. On first encounter, the ACOEM elaboration of the 11 EOM (as well as the 14 Clinical) Competencies appears to expand significantly the knowledge base to be transmitted through the academic curriculum. This immediately raises a critical design question: “In what breadth and depth are these multiple knowledge stores to be acquired, sufficient to build the sound foundations that underlie the required competencies?” Before addressing this question, several major constraints and realities that affect this issue must be recognized:
The 2-Year Instructional Program
This period of time for presentation of an EOM curriculum imposes an inelastic and immediate time constraint on the depth and breadth of the instruction required for producing even the ACOEM’s 11 EOM Competencies. The breadth of multidisciplinary bases subsumed by each Competency and the limited time available for their presentation stands in glaring contrast to other medical specialty education programs (eg, 7 years training in hand surgery).
The EOM Practice Setting
The complex and broad range of problems in Environmental and Occupational Health are frequently managed and resolved by teams providing a variety of special expertise, or, at least, by recourse to consultation by solo EOM practitioners. Although facilitated interdisciplinary consultation requires communication competence, it does not require equal depth of knowledge for each involved professional.
Subsequent Practice-Based Expansions of Competencies
Experience shows that during the course of their careers, OM specialists encounter diverse and complex EOM problems that require continued and deeper study and research in several cognates (eg, toxicology, ergonomics). This frequently eventuates in a subsequent expansion of breadth and depth of knowledge and enhanced or additional competencies; often, a highly specialized and professionally recognized expertise ensues. Accordingly, curricular design should anticipate such subsequent developments but should not be expected to provide all of the knowledge in similar breadth and depth.
As a starting point for dealing with this difficult question, there seems to be general agreement that cognates heretofore designated by the Accreditation Council for Graduate Medical Education Special Requirements 1 and regarded here as Core probably require the maximally appropriate and feasible degree of depth and breadth in the curriculum. Likewise, in this category clearly belongs both those derivatives of general clinical skills and competencies, namely, Clinical Preventive and Clinical Occupational Medicine.
In addition, the centrality of Environment to EOM practice indicates its primacy in the curriculum. However, it is also readily apparent that environment-related knowledge elements encompass a wide breadth of understanding. Accordingly, this suggests that this broad array of cognate knowledge logically cannot be provided at any uniform depth of instruction. For example, resident instruction in toxicology should not attempt to provide the depth of knowledge expected of individuals completing doctoral programs in that discipline. Knowledge needed to design and implement animal toxicity studies is of dubious utility in the practice of EOM; however, knowledge sufficient to critically review and assess such studies is required. Furthermore, the appropriate breadth of learning necessary is equally difficult to define in simple terms. As an example, a physician’s breadth of knowledge may be equal or even broader than that of a PhD toxicologist, particularly if clinical and therapeutic elements are added to the former’s knowledge base. Finally, this variability is highlighted by the array of disciplines required to deal with environmental issues. Cognate knowledge derived from or closely related to Life Sciences is more readily acquired by EOM residents. However, although an in-depth study of the physical science based elements underlying industrial hygiene analytic methodologies might be desirable, its added value to the EOM curriculum is limited.
Most importantly, EOM physicians should be provided with knowledge in sufficient depth to facilitate communication with other team members/disciplines involved in Occupational Health and Safety. Equally important, their depth of knowledge should be sufficient for a realistic understanding of what each of these fellow professionals can contribute to problem solution. At the least, they should be provided with enough knowledge to begin to practice critical analysis.
However, the critical issue of the appropriate depth and breadth of knowledge to be acquired is not susceptible to simplistic, universal formulations. Rather, all of these determinations of breadth and depth will ultimately require for each individual curricular cognate Information Needs Analyses appropriate to competent EOM practice in a multidisciplinary society.
A New Organizing Construct for Knowledge Acquisition
In view of the foregoing knowledge transfer concerns and the derived curricular design issues, an alternative Knowledge-Transfer Construct is proposed that could assist in resolving instructional design issues.
Before proposing this organizing approach, it is appropriate to present this institution’s orientation to EOM specialist education. For the past 44 years, physician education has been based on a curriculum meeting the requirements of the American Board of Preventive Medicine and directed toward producing certified EOM “specialists.” Such physicians are expected to develop competencies directed toward addressing the concerns and needs of populations of workers and communities confronted by environmental health issues.
I would conclude that at best one can only qualitatively differentiate various depths of knowledge required in the education of EOM specialists. Also, it seems that the relative breadth of knowledge (eg, see the ACOEM requirements5 for competencies in “Management,” “Administration,” or “Human Behavior”) required of EOM medical practioners is wider than that required in Industrial Hygiene, Ergonomics, Health Physics, and so forth.
Accordingly, this proposed organizing construct could provide a useful framework for determining which curricular cognates are most important and appropriate to the building of competencies. On this basis, it would seem to be useful to organize the EOM curriculum about two relatively different depths and variable breadths of knowledge. Thus two differing cognate knowledge categories are proposed: Core Knowledge (Table 1) and Augmentive Knowledge (Table 2).
The first of these, the Core Knowledge (Table 1) base generally requires development both in breadth and depth. Multiple disciplinary cognates, such as Industrial Hygiene, Toxicology, Ergonomics, etc, have not been specifically enumerated; rather, they and other cognates are subsumed within the knowledge required to develop such Competencies listed in the ACOEM report. 5 Thus, under the rubric of Environment, Workplace, and General, cognates such as toxicology and the knowledge elements of other professional disciplines (eg, Industrial Hygiene, Ergonomics, Health Physics) are implicit.
The second category, Augmentive Knowledge, largely derives from non-life science based disciplines and/or degree-associated professions (eg, law, engineering, finance and management, sociology). For the competent practice of EOM, the need for knowledge of varying depth in these cognate areas is undeniable. However, I do not believe it is the aim of education in EOM to produce “amateur” lawyers or “quasi-MBAs.”
Accordingly, this body of Augmentative Knowledge (Table 2) is suggested on the premise that a broad comprehension and integration of this additional knowledge store is needed to augment the Core Knowledge base. I do not assert that the foregoing curricular organization model is totally inclusive, nor do I preclude possibilities that other organizing arrangements might be more appropriate to other residency training programs. This proposal suggests simply an organizing construct for curricular design, which is feasible given present time and resource constraints. Finally, concerns for potential curricular insufficiencies should be moderately assuaged by realities such as: (1) graduates in the course of subsequent practice probably will expand their competencies, and (2) effective collaboration with fellow professionals also most probably will expand both the knowledge and competencies of our graduates.
Competence: Its Primacy and Some Brief Concerns
Although the cogency of this reorientation can be endorsed, its formulations have raised some problems. As previously noted regarding the 2-year term of residencies in PM, the extent of competency developed in such educational programs cannot reasonably be equated or compared with what would be expected, for example, after the 5 to 7 years of training and repetitive experience provided in surgical training programs. The use of the multidisciplinary knowledge base inherently required in EOM practice further heightens its contrast with procedure-based clinical specialty Competencies. One or even several experiences with the process of coherent marshaling, assembling, and integrating several multidisciplinary knowledge stores leading to competent behavior does not confer immediate competency. Given the variability of the constituent facts and the wide diversity of knowledge and interdisciplinary elements seen in EOM problems, consistently competent professional behaviors realistically can be expected only after a number of iterations of these problem-solving processes.
Concerns about realistic expectations for competency development arise in part from the 1993 HRSA Competencies Report, which noted that “… competencies are stated in terms of what should be expected of residents when they graduate6 [italics mine].” Immediately after that statement, the Report admits “… that residents may not have performed every Competency… while in training… ,” but this disclaimer leaves educators with a sense of discomfort—particularly after considering the 32 Competencies they list! This disquietude is further augmented by the ACOEM list of 11 EOM specialist Competencies (plus 14 other clinical Competencies!), although they, too, posit that “… no one will become expert in the listed competencies.”4 Although these imposing—and rational—lists may reflect the needs of credentialing and financial disbursement agencies, I do not believe that such expectations are realistic or appropriate to graduates of 2-year PM programs. Indeed, apparently a number of reviewers of the HRSA Report indicated concerns that such Competencies might be used for accrediting or credentialing rather than educational purposes. 6
Professionalism: What is It? How Can We “Teach” It?
At its heart and in its best sense, professionalism enjoins adherence to a code of technical and ethical standards. Upon these behaviors, each profession and each of its practitioners stands or falls contingent upon adherence to its basic ethos. We especially hold one of the medical profession’s basic ethos to be self-evident; that is, inherently, it must be seen as and act as a helping profession. Interestingly, the Oxford Unabridged Dictionary defines ethos as “… the character, sentiment or disposition of a community or people; the spirit which actuates manners and customs and especially moral attitudes practices and ideals7 [italics mine].”
In effect, at their base all professions and their members are inherently expected to have a moral foundation underlying their behavior. Over time, ours has generally been seen as possessing such a foundation. But as is the case in all professions, we are apt to be judged failures by the public and our colleagues if we do not conform to medical standards of behavior, or—at worst—we suffuse our behaviors with those of business “ethics.” The complexities inherent in OM’s ethical role in a market-based culture have been the subjects of entire treatises 8; no simple solutions can suffice.
In addition to a fundamental moral behavior, other basic technical standards of behavior are expected of each member of the profession: (1) Social and Cultural Awareness, (2) Critical Analysis, and (3) Lifetime Learning.
The importance of developing social and cultural awareness in the practice of EOM cannot be minimized. The world in which EOM is practiced inherently thrusts physicians into the nexus of potentially socially conflicting needs and perceptions associated with, for example, labor–management disagreements or environmentally impacted communities. In the course of their practice, EOM professionals will operate and be judged within the context of such conflicted environments. Codes of ethics provide but general guidance for role definitions; realistically, the difficulty with controverted “facts” lies in their “trans-science” nature. Honestly and effectively navigating such shoals requires an awareness, responsiveness, and sensitivity to one’s own reactions as well as to those of one’s social partners in such settings. The potential risk of having one’s own actions perceived as biased or inequitable, and thus unprofessional, is particularly enhanced in the world of work. Such realities demand that cultural and social sensitivities be vigorously cultivated among EOM residents in the course of their education.
One of the greatest science-related challenges facing professional graduate education is to develop the capacity for critical analysis; the educators’ eternal dilemma remains, eg, “How may such behaviors be ”taught“? Educators can begin to nurture that capacity by introducing the contrarian view, by requiring in-depth investigation of reference text statements, or by requiring students to defend their own perception or interpretation of reported observations or conclusions at journal clubs, seminars, etc. But with regard to developing the capacity for critical analysis, only long-term application of those processes associated with critical thinking will help solidify that thought process. Most importantly, these behaviors, particularly lifetime learning, are inculcated through the example set by teachers and educators. Unlike obscenity, simply seeing or even recognizing critical thinking is insufficient to instill this proficiency inasmuch as it evolves only after years of critical study and wide comprehension of the literature. But, ultimately, the rigor and clarity of each individuals’ thought processes applied over the years will determine the development of critical thinking.
Summary and Conclusions
The multistep process of education is delineated by the sequential phases: (1) Knowledge Transfer, (2) Competence Development, and (3) Professional Inculcation. The realities of practice modes and curricular time constraints are important determinants of the breadth and depth of the information provided in the Knowledge Transfer process. Accordingly, it is proposed that Phase 1, the Knowledge Acquisition Process, be organized into two components: (1) Core Knowledge, requiring both significant breadth and depth; and (2) Augmentive Knowledge, providing wide breadth and appropriate but variable depth.
This curricular organizing proposition recognizes that: (1) the wide breadth of multiple stores of knowledge inherent in the practice of PM and EOM considerably exceeds many other medical specialties; (2) the duration of training is inherently shorter; and (3) its practitioners generally operate as members of teams consisting of other professionals (eg, attorneys, engineers, business administrators, industrial hygienists, sociologists, psychologists). Obviously, it is unreasonable to expect the members of such teams to each have comparable depth and breadth of knowledge. A broad knowledge base, implicit in Augmentive Knowledge, provides the capacity for recognition, understanding, and application of capabilities brought by other professionals. Facilitating communications between team members, each possessing a broad knowledge base, enhances the effectiveness of the knowledge, competence, and professionalism of collaborative efforts.
Phase 2, Competency, consists of the coherent integration of multiple stores of information applicable to the management of a clearly defined task with a clearly measurable outcome. The accomplishment of true competency is not based on the simple possession of multiple stores of knowledge; rather it depends on the facility and effectiveness with which information bases are marshaled, integrated, and communicated. Clearly, the effectiveness of this process increases with its interaction; it is unreasonable to expect a significant degree of competence immediately upon graduation from a training program.
Phase 3, Professionalism, and its basic ethos provides the governing context for the sound application of competencies. Although it is difficult to teach, only with its accomplishment can the educational process be considered whole, albeit never complete.
*The use by this organization of the term competency apparently evolved gradually. It segued from the term skill as used in the American College of Preventive Medicine 1987 Document (ie, skill: effective application of knowledge) to later emerge in the 1993 HRSA Report as “skills and competence. ”
†We note that these two categories reflect current classifications of OM specialists extant in Europe. There, OM practitioners are limited in the breadth of practice by statute and regulation, eg, the Certificated (CES) “generalist” and Diplomate (DES) “specialist” in France and, similarly, the “Betriebsmedizin” and the “Arbeitsmedizin,” respectively, in the German Federal Republic. Application of this not unreasonable approach within the US legal system presents some problematic implications.
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