Presentation on theme: "Building and Assessing Competence"— Presentation transcript:
1 Building and Assessing Competence David C. Leach, M.D.Executive DirectorACGMESeptember 12, 2002
2 ObjectivesTo clarify what you have known all of your professional life about competenceTo explore how residents learn to make good clinical judgmentsTo define specific steps that can be taken to respond to the ACGME Outcome Initiative
3 Yet can also be immensely satisfying. Reasons this is hardYet can also be immensely satisfying.
5 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
6 Why worry about it? Public concerns with safety Variability in patterns of care that are not based on sciencePoor customer service
7 ACGME Outcome Project The Project A long term initiative The Vision to enhance residency educationThe Process through educational outcome assessment
8 Reason Number Two ACGME/RRCs judge competence of Programs Boards judge individuals
9 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 programsThese relationships can either inhibit or facilitate learning
10 So what do we accredit? Humans? Sets of relationships? Educational outcomes?
11 Reason Number Three Humans: the important things are hard to measure
12 Dee Hock’s Criteria for Hiring People IntegrityMotivationCapacityUnderstandingKnowledgeExperience
13 Reason Number Four Knowing the rules is not enough Residents need to prepare for the unknown
20 Dreyfus Model of Skill Acquisition NoviceAdvanced BeginnerCompetentProficientExpertMaster
21 Dreyfus Model Novice Rules Advanced Beginner Rules + Situation CompetentRules + Selected Contexts + AccountableProficientAccountable + IntuitiveImmediately sees whatExpertImmediately sees howMasterDevelops styleLoves surprise
22 “To become competent you must feel bad” Hubert Dreyfus
23 Between Advanced Beginner and Competent The number of potentially relevant details becomes overwhelmingExhausting to manage with rulesChoose a perspectiveResult depends on the perspective adopted by the learner/risk takingFright replaces exhaustion
24 Two Paths Go back to rules Become fully involved Cycle between advanced beginner and competentBurn outBecome fully involvedFeel bad when wrong and good when right
25 NextProficient intuition replaces reasoned responses. - immediately sees the problem - recognizes patternsExpert immediately sees how to solve problemMaster – styles, continuous learning
26 Conceptual Model Patient Care Med Know Practice Based Learning Inter & Comm SkillsProfess-ionalismSystem-based PracticeNoviceAdvance BeginnerCompProficientExpertMaster
29 Accreditation Aside Minimal threshold Do your graduates know the rules?Can they apply them in complex contexts without supervision?
30 Accreditation Aside Improvement Model Do your graduates have the habit of accountability?Have they acquired practical wisdom?
31 Reason Number SixThe quality of the program is dependent on the quality of the relationships.
32 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.
33 Cooperative Arts Medicine cooperates with the body’s natural tendency to healTeachingcooperates with the mind’s natural tendency to ascend to the truthManagementcooperates with people’s natural tendency to form communities
35 Real learning (intelligent adaptation) occurs in microsystems And sometimes in macrosystems.
36 Health care systems consist of macrosystems and microsystems Paul Batalden, M.D.
37 Substance is enduring; form is ephemeral Substance is enduring; form is ephemeral. Preserve substance; modify form; know the difference.Dee Hock
38 Substance attracts resources; form attracts expenses. Dee Hock
39 Microsystems have a high substance to form ratio; macrosystems have the reverse.
40 Characteristics of High Performing Microsystems Integration of informationMeasurementInterdependenceSupportiveness of the larger organizationConstancy of purposeInvestment in improvementAlignment of roles and trainingConnection with community Julie Mohr, Ph.D.
41 This is a big opportunity for improvement. Reason Number SevenIntroducing learners can enhance or inhibit the function of a microsystem.This is a big opportunity for improvement.
42 Rehearsals are good for relationships and outcomes. A restaurant in ChicagoSimulation offers a huge opportunity for improvement.
44 Useful Concepts about Measurement Life is not condensableWe use models to understand lifeAll models are limited, some are usefulMeasurements are applied to modelsBoth measurements and models must be constantly reassessedWe need structured dialogue about measurement
45 Useful Concepts Rules and context Science is universal; art is always uniqueObjective and subjective
46 Characteristics of good assessment Measures actual performanceIdentifies areas for improvementSatisfies reasonable request for accountabilityIs practicalIs done over time to discern growth
51 Forming the Initial Response Show evidence of initial plansInstitutions build in competencies and their assessment into internal reviewsChange the verbsStart with Global AssessmentsOrganize Focused AssessmentsPatient and/or Professional Associate Assessment
52 What if you were crazy enough to go beyond the minimal? What would an improvement model look like?
53 Accreditation Aside Minimal threshold – hide flaws Improvement – expose problems and show how they were addressedRequires much greater trust
54 Excellent programs will use rehearsals. Simulations are not the same as simulators
55 Excellent programs will develop virtuous cycles between the microsystems and education.
56 Excellent programs and institutions get to pick their own indicators. Remember the Northern New England Cardiovascular Surgery experience.
57 Abba Felix Desert Father “To teach is to create a space in which obedience to truth is practiced.”Abba FelixDesert Father
58 What we attend to and how we attend to it defines who we are.
59 A Community of Practice General CompetenciesOpen data systemsCelebrate benchmarks across disciplinesBuild knowledge about medical educationBuild knowledge about improving patient careEnhance public accountability
60 To Teach/Learn is to create a Space/Community in which obedience to truth is practiced.