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My core incompetencies

DII small banner By Warren R. Heymann, MD
May 19, 2017

It is time for our semiannual ritual — the meeting of our Clinical Competency Committee (CCC). Our dermatology program is small, having twice as many faculty members as residents, so everyone serves on the committee. The process has changed dramatically from the time I was our program director (which ended just as core competencies were being implemented). I am infinitely grateful to Analisa Halpern, who now has this role, for her efforts in collating data with her infectious smile and enthusiasm. If I was program director today, I’d be flummoxed and scowling.

The Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) have jointly identified six domains of general competencies: 1) Patient Care; 2) Medical Knowledge; 3) Practice-based Learning and Improvement; 4) Interpersonal and Communication Skills; 5) Professionalism; and 6) Systems-based Practice (1). For each competency, milestones are elaborated in detail; the committee assesses each resident for every competency. They are scored from 1 (the lowest level, expected of a neophyte) to 5 (the ultimate master). The importance is to demonstrate progress over the three years, so that the resident ultimately reaches a level compatible with independent practice.

After this whirlwind, I usually ask myself “what just happened?” I’m sure that we strive to be just in our evaluations, but I always feel uneasy with the process without understanding why. Dickey et al (2) crystallized my nebulous ruminations — I suffer from cognitive load and bias.

Dickey et al state: “In CCC deliberations, members often need to make more than 20 milestone-level determinations per resident. This represents high cognitive load, with the potential for decision-making fatigue, which degrades decision-making processes.”  I’m numb after evaluating just a few residents — I extend my sympathies to CCC members of large residency programs.

Most importantly, I know that I have been guilty of every one of the biases presented by Dickey et al. If you have ever served on any committee, you will recognize these, and must have experienced several of them yourself. In alphabetical order, potential biases include: 1) Anchoring (Holding on to an initial observation or opinion and not acknowledging changes); 2) Availability (Giving preference to data that are more recent or memorable); 3) Bandwagon (Believing things because others do); 4) Confirmation (Focusing on data that confirm an opinion and overlooking evidence that refutes it); 5) Framing effect (Forming an opinion on how data are presented); 6) Groupthink (Judgment influenced by overreliance on consensus); 7) Overconfidence (Having greater faith in one’s ability to make a judgment that is justified); 8) Reliance on gist (Judgments based more on context than on specific observation or measurement); 9) Selection (Relying on partial information that is not truly random or representative); and 10) Visceral (Judgment influenced by emotions rather that objective data).
The purpose of the CCC exercise is to make sure residents are progressing as we expect, while identifying specific areas that need attention. Constructive action plans can then be developed to help residents reach their potential as caring, competent, ethical physicians.

I find this process analogous to the concept that “democracy is the worst form of government, except for all the others.” (Although attributed to Winston Churchill, the origin of this comment is unknown). Our committee is not perfect, but by acknowledging cognitive load and our biases, we should be able to make our assessments more accurate.

I have one more compliment for Dr. Halpern. Fortunately, her rank lists have brought us fabulous residents, making our committee work as easy as possible — thank you Ana!

1. Williams BW, et al. Miller’s pyramid and core competency assessment: A study in relationship construct validity. J Cutin Educ Health Prof 2016: 36: 295-9. For each competency, milestones are elaborated in detail ; the committee assesses each resident for every competency.
2. Dickey CC, et al. Cognitive demands and bias: Challenges facing clinical competency committees. J Grad Med Educ 2017; 9: 162-4.

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