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Building and Assessing Competence. David C. Leach, M.D. Executive Director ACGME September 12, 2002. Objectives. To clarify what you have known all of your professional life about competence To explore how residents learn to make good clinical judgments
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Building and Assessing Competence David C. Leach, M.D. Executive Director ACGME September 12, 2002
Objectives • To clarify what you have known all of your professional life about competence • To explore how residents learn to make good clinical judgments • To define specific steps that can be taken to respond to the ACGME Outcome Initiative
Reasons this is hard Yet can also be immensely satisfying.
Competence“…the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.”Epstein and Hundert JAMA, Jan. 9, 2001
Why worry about it? • Public concerns with safety • Variability in patterns of care that are not based on science • Poor customer service
ACGME Outcome Project • The Project A long term initiative • The Vision to enhance residency education • The Process through educational outcome assessment
Reason Number TwoACGME/RRCs judge competence of Programs Boards judge individuals
A slight problem … • We accredit programs • Programs don’t exist • The only things that are real are the humans and the relationships between humans in so-called programs • These relationships can either inhibit or facilitate learning
So what do we accredit? • Humans? • Sets of relationships? • Educational outcomes?
Reason Number ThreeHumans: the important things are hard to measure
Dee Hock’s Criteria for Hiring People • Integrity • Motivation • Capacity • Understanding • Knowledge • Experience
Reason Number FourKnowing the rules is not enough Residents need to prepare for the unknown
Stacey, 1996 - Chaos Zone Of Complexity Agreement Control + + Certainty -
“Needed are a few organizing principles to have conversations about our work.” Marvin Dunn, M. D. Paul Batalden, M.D.
Organizing Principles • General competencies • Continuum • Measurements • Improvement models
The General Competencies • Patient care • Medical Knowledge • Practice-based Learning and Improvement • Interpersonal and Communication Skills • Professionalism • Systems-based Practice
Accreditation Aside “You must call your mother every Sunday.” Prescription or invitation?
The Continuum Life after competent
Dreyfus Model of Skill Acquisition • Novice • Advanced Beginner • Competent • Proficient • Expert • Master
“To become competent you must feel bad” Hubert Dreyfus
Between Advanced Beginner and Competent • The number of potentially relevant details becomes overwhelming • Exhausting to manage with rules • Choose a perspective • Result depends on the perspective adopted by the learner/risk taking • Fright replaces exhaustion
Two Paths • Go back to rules • Cycle between advanced beginner and competent • Burn out • Become fully involved • Feel bad when wrong and good when right
Next • Proficient - intuition replaces reasoned responses. - immediately sees the problem - recognizes patterns • Expert - immediately sees how to solve problem • Master – styles, continuous learning
Reason Number Five Residents seek practical wisdom
Aristotle • Episteme • Cognitive knowledge, science • Techne • Craft/Art of medicine • Phronesis • Practical wisdom
Accreditation Aside Minimal threshold Do your graduates know the rules? Can they apply them in complex contexts without supervision?
Accreditation Aside Improvement Model Do your graduates have the habit of accountability? Have they acquired practical wisdom?
Reason Number Six The quality of the program is dependent on the quality of the relationships.
Medicine, education and management are cooperative arts rather than productive arts. Therefore the quality of the activity is dependent on the quality of the relationships.
Cooperative Arts • Medicine cooperates with the body’s natural tendency to heal • Teaching cooperates with the mind’s natural tendency to ascend to the truth • Management cooperates with people’s natural tendency to form communities
Real learning (intelligent adaptation) occurs in microsystems And sometimes in macrosystems.
Health care systems consist of macrosystems and microsystems Paul Batalden, M.D.
Substance is enduring; form is ephemeral. Preserve substance; modify form; know the difference. Dee Hock
Substance attracts resources; form attracts expenses. Dee Hock
Microsystems have a high substance to form ratio; macrosystems have the reverse.
Characteristics of High Performing Microsystems • Integration of information • Measurement • Interdependence • Supportiveness of the larger organization • Constancy of purpose • Investment in improvement • Alignment of roles and training • Connection with community Julie Mohr, Ph.D.
Reason Number Seven Introducing learners can enhance or inhibit the function of a microsystem. This is a big opportunity for improvement.
Rehearsals are good for relationships and outcomes. A restaurant in Chicago Simulation offers a huge opportunity for improvement.
Useful Concepts about Measurement • Life is not condensable • We use models to understand life • All models are limited, some are useful • Measurements are applied to models • Both measurements and models must be constantly reassessed • We need structured dialogue about measurement
Useful Concepts • Rules and context • Science is universal; art is always unique • Objective and subjective
Characteristics of good assessment • Measures actual performance • Identifies areas for improvement • Satisfies reasonable request for accountability • Is practical • Is done over time to discern growth
www.acgme.org/Outcome/ • Assessment toolbox • References • Table of “best methods” • Key considerations in selecting and implementing assessment approaches • Assessment approaches
RRC Think Tank • Chair Gail McGuiness, M.D. • Clarify expectations for programs • Clarify operational issues for RRCs • Identify PIF questions relevant to assessment for relational database