Presentation on theme: "Building and Assessing Competence David C. Leach, M.D. Executive Director ACGME September 12, 2002."— Presentation transcript:
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 ProjectA long term initiative The Visionto enhance residency education The Processthrough educational outcome assessment
Reason Number Two ACGME/RRCs judge competence of Programs Boards judge individuals
A slight problem … We accredit programs Programs dont 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 Three Humans: the important things are hard to measure
Dee Hocks Criteria for Hiring People Integrity Motivation Capacity Understanding Knowledge Experience
Reason Number Four Knowing the rules is not enough Residents need to prepare for the unknown
Agreement Certainty + + - - Chaos Zone Of Complexity Control Stacey, 1996
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?
Dreyfus Model of Skill Acquisition Novice Advanced Beginner Competent Proficient Expert Master
Dreyfus Model NoviceRules Advanced BeginnerRules + Situation CompetentRules + Selected Contexts + Accountable ProficientAccountable + Intuitive Immediately sees what ExpertImmediately sees how MasterDevelops style Loves surprise
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
Conceptual Model Patient Care Med Know Practice Based Learning Inter & Comm Skills Profess- ionalism System- based Practice Novice Advance Beginner Comp Proficient Expert Master
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 bodys natural tendency to heal Teaching cooperates with the minds natural tendency to ascend to the truth Management cooperates with peoples 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
Forming the Initial Response Show evidence of initial plans Institutions build in competencies and their assessment into internal reviews Change the verbs Start with Global Assessments Organize Focused Assessments Patient and/or Professional Associate Assessment
What if you were crazy enough to go beyond the minimal? What would an improvement model look like?
Accreditation Aside Minimal threshold – hide flaws Improvement – expose problems and show how they were addressed Requires much greater trust
Excellent programs will use rehearsals. Simulations are not the same as simulators
Excellent programs will develop virtuous cycles between the microsystems and education.
Excellent programs and institutions get to pick their own indicators. Remember the Northern New England Cardiovascular Surgery experience.
To teach is to create a space in which obedience to truth is practiced. Abba Felix Desert Father
What we attend to and how we attend to it defines who we are.
A Community of Practice General Competencies Open data systems Celebrate benchmarks across disciplines Build knowledge about medical education Build knowledge about improving patient care Enhance public accountability
To Teach/Learn is to create a Space/Community in which obedience to truth is practiced.