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Internal
Medicine On Line Curriculum Competency-based Patient-centered Primary care focused |
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 Table of Contents: 1-Introduction: Competency as an Outcome 2-Overview of the Curriculum: Competency-based Education 3-Goals & Objectives Common to All Rotations:
5-Educational Process Summary:
1-Introduction: Competency as an Outcome Welcome to the On Line Curriculum of the Internal Medicine Residency of St. Barnabas Hospital! When viewed from an internet connected computer, this document should allow you to hyperlink to many of the resources you will need as part of your educational syllabus. While based on American Board of Internal Medicine (ABIM) and Accreditation Council for Graduate Medical Education (ACGME) requirements, this curriculum is not meant to reproduce a textbook of medicine. The curriculum was developed to provide our medical residents with an overview of certain outcomes we expect residents to achieve: these are specific knowledge, skills, attitudes, behaviors and habits residents are expected to demonstrate, progressively, over the course of three years. This curriculum is reviewed annually by both faculty and residents. Thus it is meant to include suggestions from the residents themselves regarding topics of interest.
The ACGME has the authority to accredit our residency. The ABIM certifies residents. Both the ABIM and the ACGME want us to confirm if, after three years of training, a resident is competent to practice medicine. Specifically, the ACGME requires that we have measurements of certain outcomes to document that our residents are competent before we recommend that residents be permitted to take the ABIM Certifying Examination in Internal Medicine. You will see the concept of measurable outcomes to document competency as a recurring theme. What is meant by competent? While there are many definitions of
competent, the executive director of the ACGME, Dr. David Leach,
subscribes to the
Based on the table above, one might view the senior medical student and/or beginning PGY-1 as "novice", following the rules in the Washington Manual. By the end of the PGY-1 year, the resident ("advanced beginner") should be able to adapt the rules to various situations. And no later than the end of the PGY-3 year should residents have reached the "competent" stage. Where might you expect to place a Chief Medical Resident, or a Division Chief? Dr. Leach also sees competency as part of a habit:
"Physicians are thought to be competent when they habitually incorporate
three elements into their daily work:
Dr. Leach explains that when a resident completes three years of training and passes the certifying board examination, they are "qualified". But to say that they are "competent" means that they incorporate the above three habits into their daily practice. By graduation, competent residents should be capable of functioning at the level of a new independent practitioner.
This syllabus starts with a general overview and proceeds to more individual rotations Most topics in this curriculum will be presented in the following (competency-based) format: I. Introduction ("Nuts & Bolts") So for a curricular rotation and/or topic, such as Neurology, this document and its links, will usually be organized as follows: I. The Introduction describes the "nuts and bolts" of the rotation. This includes where you meet, the weekly schedule of activities, your responsibilities and chain of command. II. The Outcomes (competencies) expected are those measurable Goals and Objectives such as the knowledge, skills, attitudes, behaviors and habits you should master. III. The Educational Process for achieving the Goals & Objectives will include a description of the experiences on rotations (with guidance) that will result in a feeling of success; lectures and conferences that will provide residents with a feeling of readiness for new skills and knowledge; references, web sites, handouts which should allow residents to feel confident when participating in self-directed independent study. IV. Outcome Measurements to assess that you are meeting the Goals and Objectives. These might include, for example, direct observation of interviewing and physical examination techniques, quizzes, In-Training Examinations, portfolios, and self-reflection. And, of course, where and how you will receive feedback. Thus, when assigned to the Neurology Service, you might be expected to become knowledgeable about meningitis, learn how to proficiently perform a lumbar puncture and interpret the results, and how to communicate with the patient in a manner that provides humanism and professionalism. And you would be expected to meet with your preceptor mid-way through the rotation for a "formative" assessment, and at the end of the rotation for "summative" assessment.
2-Overview of the Curriculum: Competency-based Education As noted above, the Curriculum describes the competencies to be acquired, the experiences necessary to achieve this, and an assessment process (with feedback). To ensure that competency is achieved, we utilize the following framework:
Using measurable outcomes to document competency is referred to by many as "competency-based education". The paradigm of competency-based education is described in the diagram above by Dr. Hershey Bell. This logical strategy is predicated on the concept that faculty will tell residents which competencies they need to master; then instruct the residents; then provide formative assessment/feedback ("educational Dx & Rx") to the resident as to how they are doing. And with a boost of encouragement, the resident should be able to demonstrate mastery (well at least competence) of the particular skill.
Depending on the competency which is being assessed, the ACGME suggests several different techniques from its "toolbox" which may used to document competency:
At the end of three years of training, the ABIM will ask our faculty if a resident has developed clinical competence in Internal Medicine. If the answer is "yes", then the resident will be permitted to take the Certifying Examination in Internal Medicine. After passing the examination, the resident will be granted a time-limited (10 year) board certification in Internal Medicine. Prior to 2003, as described in the ABIM document "Residents: Evaluating Your Clinical Competence", the faculty had been asked if residents developed clinical competence in the following areas: -Medical Knowledge
Starting in 2003, the ABIM has aligned its Clinical Competencies with the six General Competencies of the ACGME (more about these in the next section).
The ABIM particularly desires that our faculty evaluate those attitudes and behaviors which make up core values of Internal Medicine that can not easily be measured on a standardized test.
3-Goals & Objectives Common to All Rotations As part of a several year process, the ACGME has mandated that ALL residency training programs (not just Internal Medicine), teach and assess the following six General Competencies: 1. Medical Knowledge
(MK)
The actual language of the ACGME is as follows:
As Dr. Hershey Bell schematically outlines in the following "integrated competency" diagram, many medical issues or encounters will fall under the heading of more than one major competency:
To remind faculty of these cross relationships, and to review all six of the "integrated" major competencies while on rounds, Dr. Bell suggests bringing along a form like the following "ACGME Outcome Project Rounds Worksheet":
As you can see, the ACGME General Competency definitions can appear broad, general, and sometimes difficult to apply to Internal Medicine. So for the purposes of our Internal Medicine Residency, we will try to provide clarity by utilizing the components of the Six General Competencies as formulated by the ABIM in the previous section titled: ABIM 2003 Clinical Competencies.
Although the ACGME expects residency training programs to develop their own methods (using suggestions from the "ACGME Toolbox") to assess that the Six Major Competencies are being learned, in broad strokes they envision the following assessment strategy:
Dr. Leach points out that four general assessment tools seem to be emerging as useful measures of competence: (1) direct observations of the resident over time, especially focused assessments of particular skills; (2) portfolios of residents' clinical experience; (3) 360-degree evaluations from colleagues, nurses and patients, and (4) cognitive examinations. Each can be formative and summative. The ACGME offers a tabular view as a model assessment of the Six Major Competencies as well (using the evaluation tools from the ACGME Toolbox, above):
For the Primary Care Oriented Catagorical Internal Medicine Residency at St. Barnabas Hospital, we are continually revising our methods for teaching as well as assessing the Six Major Competencies. What follows is our current assessment strategy; [ ] indicates in planning stages:
CSR = Chart Stimulated Recall
HB = utilizes vignettes from Dr. H. Bell
4-Educational Process
The specific rotations arranged for each year of residency are key experiences which provide the opportunity necessary to develop certain competencies. A generic rotation schedule follows:
The ACGME requires that there be outcome measures for each level of
training, and PGY-1:
At the conclusion of this year, the resident has demonstrated sufficient
PGY-2: At the beginning of this year, the resident is
capable of making independent PGY-3: At the
conclusion of this year, the resident should demonstrate mastery of
5-Educational Process Summary: General Competencies of Adolescent Medicine
This online
curriculum is intended to be plastic. Residents and faculty
are encouraged
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