Tuesday, November 20, 2012
I train doctors.
In my role as a residency program director, I have three major responsibilities:
1) Recruiting: find and hire medical school graduates.
2) Curriculum: set educational standards to produce well-qualified internists.
3) Accreditation: comply with national professional norms and requirements.
Regarding #2, the goal is to have trainees demonstrate competence as doctors at the end of the three-year training period (residency). Ideally, they acquire it in steady, graded fashion at distinct mileposts along the way, so that teaching faculty know that residents are making adequate progress and will flourish as independent doctors.
How do professions measure and determine competence? In medical training, residency programs are subject to regulations provided by "Residency Review Committees" which are empowered by a national accrediting body. Those committees come for periodic site visits to inspect our training environment and make sure that we're following best practices (and the rules).
It's up to us to comply with their rules, but we have leeway in interpreting them so that there can be innovation in how we implement our educational models.
Over the last 15 years, the national governing body was able to choose six "core competencies" that defined competence for doctors of all specialties. Regardless of what kind of medicine you practice, there should be fundamental attributes that all doctors share, right?
Those six competencies are:
--patient care (duh)
--medical knowledge (also duh)
--interpersonal skills and communication (hey, I kinda like that.)
--professionalism (for sure, right?)
--systems-based practice (huh?)
--practice-based learning & improvement (I think you lost me on these last two)
Give yourself an exercise: Now that you know the domains of competency, how would you evaluate learners in those domains?
Perhaps unsurprisingly, medical educators began resorting to numeric grading scales to evaluate residents in each of these domains. This allowed for quantification of residents' performances, and a better ability to document both interval progress and ultimate competence.
The problem became that different faculty members interpreted the grading scales differently. Grade inflation starting making nearly everyone look the same, as far as their evaluation numbers were concerned. Asked to define what makes a competent physician, faculty responded along the lines of Supreme Court Justice Potter Stewart, who famously quipped about the hard-to-define-concept of obscenity "I know it when I see it."
Voila, welcome to the Next Accreditation System (NAS). Program Directors like me across the country are currently struggling to implement this new system, with a goal of allowing more detailed analyses of learners' performances. Another goal of the new system is to allow more freedom and flexibility in educational innovation by making reporting requirements more frequent but less onerous (hey-will that work?) to keep educators' eyes more fixed on teaching and training than on evaluating and reporting. [I'm imagining that in the near-term, there will be a lot of the latter. I hope the former is not diminished.]
The new system is predicated on developmental milestones that lead doctors to become competent in a range of entrustable professional activities ("EPAs"). These EPAs map to the original six competencies which I shared with you above.
At a recent national meeting discussing these changes and strategies for handling them, one colleague likened these new mandates to "repairing the airplane while flying it."
No one ever said that change is easy. Best for us to embrace it and make it a learning opportunity.
This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
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Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.