By Ruth Carol, contributing writer, July 01, 2013
In the 1980s, the Accreditation Council for Graduate Medical Education (ACGME) began emphasizing program structure in an attempt to eliminate variability in the quality of resident training. In 1999, it introduced the six domains of clinical competency. While the formal teaching and assessment of residents have significantly improved as a result, the number of program requirements has proliferated and become increasingly prescriptive, and some would say restrictive, during the next few decades.
This year, ACGME will roll out its Next Accreditation System (NAS), which will move toward basing accreditation on educational outcomes in these competencies. The phasing in of the NAS is also expected to reduce the burden associated with the current structure and process-based approach. More importantly, it is expected to better prepare physicians for practice in the 21st century.
Residency training evolves
Residency programs are much more uniform than when Erin Boh, MD, PhD, program director in the department of dermatology at Tulane University in New Orleans, graduated in the 1980s. “When I graduated from residency, every program emphasized what it wanted to,” she said. On a positive note, she said, the consistency ensures proficiency in knowledge and skills no matter which program residents attend. Additionally, programs now offer more procedural training. In the past, residents had to wait until they completed their training and take a weekend course or boot camp to obtain training in procedures, Dr. Boh explained. Nowadays, most residents leaving their programs are well versed in surgery, flaps, grafts, Mohs surgery, and different cosmetic procedures, including administering toxins and fillers. The downside is that there is less flexibility in what the individual programs can teach, she said. [pagebreak]
Michael Girardi, MD, professor and residency director in the department of dermatology at Yale University School of Medicine, agreed that “the rules were a lot simpler” when he began residency training in 1994. But there was also a lot more inconsistency between programs, he said. “The ACGME has enhanced the capacity of programs to hold residents to more specific standards, where progress may be better communicated and documented,” he added. “This is better for the residents, the program, and ultimately the specialty.”
The emphasis shifted from obtaining more structure and uniformity across programs with the introduction of the six core competencies, noted William James, MD, program director in the department of dermatology at the University of Pennsylvania. The competencies include medical knowledge, interpersonal and communications skills, patient care and procedural skills, professionalism, practice-based learning and improvement, and systems-based practice. They came about because of the need to involve patients more in the decision-making process, address the complexity and volume of health information available due to technology, and focus more on cost-of-care as well as providing team-oriented and evidence-based care for individuals and populations, he said.
“It’s not enough to just have the book knowledge or pass the board on medical knowledge,” Dr. James added. “You have to pay attention to these other areas.” He credits the six competencies with helping to provide a framework for residency programs to address both the clinical and non-clinical elements that affect patient care. It’s not that residents didn’t pay attention to communication or professionalism, for example, prior to the introduction of the competencies, but now they are being addressed in more depth, Dr. James said. [pagebreak]
The new competencies come with a barrage of new requirements for residency programs as well, Dr. Girardi noted. Documentation and implementation requirements, including graduated responsibilities, resident supervision, evaluation protocols, and milestones, among others, have placed a tremendous burden on residency directors and coordinators in both time and effort. “That said, when I look back on each requirement, they have for the most part helped improve resident education and patient care, and helped ensure that programs have vigorous and consistent training,” he added. “In short, they have been worth the extra effort.”
The next iteration
Whether the NAS, which will assess programs based on the reporting of outcomes, the use of milestones, and changes in their case log data, will be worth the extra effort remains to be seen. There is growing science behind the field of measuring the mastery of procedures and skills, noted Sewon Kang, MD, program director in the department of dermatology at Johns Hopkins in Baltimore. “The NAS is a reflection of this field that has evolved in recent years, trying to implement what’s been found to hopefully better train our residents.” Time will tell if it accomplishes its goal, he added.
“The core requirements of what we expect a dermatology resident to learn will remain the same,” according to Col. Nicole Owens, MD, chair of the Dermatology Residency Review Committee (RRC). “The methods and some of what we’re gathering will change.” [pagebreak]
The NAS will focus on more meaningful data and outcomes, rather than on detailed processes and program information forms — or PIFs — used to describe compliance with requirements. Instead, program directors will submit annual data, much of which is already being collected, Dr. Owens said. Clinical competency committees (CCCs) will conduct semi-annual resident evaluations using the milestones. Although the process may initially be more time-intensive, ultimately the NAS will decrease administrative burden on program directors and coordinators, she noted.
The biggest change with the NAS is that evaluators will be able to focus on specific observable skills and concrete benchmarks rather than providing an overview of a resident’s competency, Dr. James said. The milestones describe, in specific behavioral terms, the performance level expected of a resident at specific times during residency. As such, they capture the progression from a beginning learner to the expected level of proficiency at the completion of training. “The milestones offer a detail-oriented description of what levels of competency might look like in a real sense,” he said. [pagebreak]
The dermatology-specific milestones are nearing the end of alpha testing at five residency programs across the country. Based on feedback from the alpha test sites, the milestones may be tweaked and sent out for beta testing this fall.
The NAS also encourages innovation in training for programs that demonstrate high-quality outcomes as the more detailed process standards may be relaxed, Dr. James explained. For instance, if there is one resident who wants to specialize in pediatrics and one in procedural dermatology, as long as they meet the competency requirements the former can receive more training in pediatrics and the latter in surgery. “The NAS allows program directors to work within general guidelines to be more innovative as long as the program is in good standing,” he said.
The potential of additional ACGME/NAS requirements to compromise a program’s flexibility in training residents was a big concern for Dr. Girardi. Yale has a robust and successful history of training future academicians, including physician-scientists, in dermatology, he explained. “This has come, in part, from specialty tracks and other more individualized supplements to residency training that I try to tailor for each resident,” Dr. Girardi said. “Fortunately, the American Board of Dermatology understands this, and recognizes the importance and value of research and specialty tracks, and other more individualized components of dermatology training.” [pagebreak]
Dr. Boh remains concerned that the NAS will add more requirements and oversight. She acknowledges that it may improve programs, but will make them even more homogeneous. “You used to just do quality improvement, now you have to document it,” Dr. Boh said.
Transitioning to NAS
The ACGME is working hard to make it easy for program directors to transition to the NAS by using existing assessment tools and creating new ones for programs that lack such tools, Dr. Owens said. “There is a whole group of assessment tools that program directors are already using. We don’t expect those to change,” she said. “They will feed into the data that goes to the CCC.” To date, the RRC has approved five competency assessment tools including a patient survey, surgical assessment tool, and clinical observational tools, which can be found on the ACGME website.
Dr. Owens points out that many programs already have CCCs; they are just known by different names, such as Education Committee or Faculty Committee. These committees may need to be renamed and tweaked, and the NAS milestones introduced into the existing evaluation process, she said.
A hiatus on site visits that begins this month will allow programs in good standing to transition into the NAS. Dr. Owens encouraged program directors to start forming CCCs, familiarize the faculty with the milestones, and begin discussing how they will review residents using this more detailed assessment. “Taking a full year will help them in the long run,” she said. [pagebreak]
Better prepared for practice
The NAS is expected to help residents be better prepared for practice, as well. Dermatologists looking to hire can expect newly trained physicians to have optimum training with more exposure to procedural dermatology in addition to their medical dermatology knowledge, Dr. Boh said.
Hiring dermatologists should expect recently graduated residents to demonstrate a high level of competency in the six areas, Dr. James added. They should work well with members of a team within the office and referring physicians. They should be able to quickly access health information, including clinical practice guidelines, and translate it into practice.
Because the milestones are detailed descriptive behaviors, potential employers will have a more concrete sense of a resident’s capabilities, Dr. Kang noted.
Finally, recently trained physicians will be prepared to navigate Maintenance of Certification (MOC) requirements because some of the milestones have similar activities. Previously, residents learned about continuing medical education and quality improvement. The milestones kick that up a notch by having them look at outcomes and conduct self-assessments of their practice in order to improve. “Those kinds of activities included in residency training can be easily transferred into MOC,” Dr. James said.
Dr. Owens concurs. “The NAS rolls very nicely into MOC and emphasizes the continuum of learning that occurs throughout a dermatologist’s career,” she said. “These are essential skills whether you’re a first-year resident or an experienced dermatologist in practice for 20 years.” [pagebreak]
Six core competencies
- Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations.
- Patient Care and Procedural Skills: Provide care that is compassionate, appropriate, and effective treatment for health problems and to promote health.
- Medical Knowledge: Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care.
- Practice-based Learning and Improvement: Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their practice of medicine.
- Interpersonal and Communication Skills: Demonstrate skills that result in effective information exchange and teaming with patients, their families, and professional associates (e.g. fostering a therapeutic relationship that is ethically sound, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader).
- Systems-based Practice: Demonstrate awareness of and responsibility to larger context and systems of health care. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions, or sites).
New Accreditation System timeline*
July 1, 2013: Hiatus on dermatology program site visits
Spring 2014: Identify CCCs, train members on using milestones
July 1, 2014: Start using milestones to assess residents
Winter 2014: CCCs conduct semi-annual assessments
*Current timeline, subject to change
Recent AHA survey cites deficiencies in physician training
Newly trained physicians are deficient in systems-based practice, communication skills, and the ability to work within teams, according to a recent survey of hospital leaders by the American Hospital Association. The report, entitled Lifelong Learning: Physician Competency Development, suggests that resident training should go beyond the clinical to encompass the competencies that strongly impact health care delivery. Additionally, survey respondents said that the curriculum should be expanded around the science of teamwork, quality improvement, culture of innovation and safety. The report offered the following recommendations for residency training programs:
- Consider the use of inter-professional training to strengthen care delivery. Early understanding and respect for the expertise of fellow clinicians encourages strong teamwork and better efficiency.
- Involve residents in the hospital’s quality and patient safety improvement efforts as early as feasible to enable them to master the competency around practice-based learning and improvement.
- Reflect the wide variety of environments in which health care is practiced by exposing residents to new models of care delivery, including patient-centered medical homes.
- Enhance residents’ skills as advisers, counselors, and navigators to help patients make informed decisions when facing complex treatment choices. Educate residents about wellness and prevention, as well.