Resident Evaluation Clinical Competency Laura Kezar, MD Associate Professor Physical Medicine and Rehabilitation

Roles of Oversight Agencies zACGME yResidents in training yRRC accreditation process zABMS yInitial board certification and maintenance of certification Groups perceived the need for developing description of “competent physician” zResponse to external forces yErrors in Medicine Report, etc.

What is Clinical Competency? zCritical knowledge and ability to perform defining acts of our profession. yResponsibility of program director and teaching faculty to verify that residents possess the skills, knowledge, and attitudes necessary to competently practice patient care.

How Do We Evaluate It? zFormative Evaluations – day to day yFeedback given to residents on a regular basis to help them improve performance yDaily verbal interaction yCorrection of errors on H&P’s, notes y360 evaluations yPeer evaluations yReflections on lecture, workshop, committees yDo not go into the “permanent record.” yPortfolios often to show work and document improvement over time.

Daily Feedback zI see … ygive specific information zI feel … ypleased, disappointed, frustrated zI think … ythis was unprofessional yyou did a great job zI want … yyou to study this tonight and we will re-evaluate it tomorrow yYou should put this in your portfolio

How Do We Evaluate It? zSummative Evaluations yFormal Global Rotation Evaluations ySemiannual Global Evaluations yEvaluation at completion of residency to specialty board

Six Core Competencies 1. Patient Care zPatient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Six Core Competencies 2. Medical Knowledge zMedical knowledge about established and evolving biomedical, clinical, and cognate (epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

Six Core Competencies 3. Practice-based Learning and Improvement zInvolves investigation and evaluation of physician’s own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

Six Core Competencies 4. Interpersonal and Communication Skills zInterpersonal and communication skills that result in effective information exchange and teaming with patients, families, other health care professionals

Six Core Competencies 5. Professionalism zProfessionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Six Core Competencies 6. Systems-based Practice zSystems-based practice ymanifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care yability to effectively call on system resources to provide care that is optimal value.

Typical Evaluation Methods See the ACGME “Toolbox” zTeaching physician observations zWritten exams zLearning objectives and evaluations zMedical record audits z360 Evals

Evaluation Methods zComputer simulated patient encounters zClinical Evaluation Exercise (CEX) zMini CEX zStandardized patients (Objective Structured Clinical Examination (OSCE)

Learning Objectives and Evaluations zSupervision of residents by clinically competent physicians - the ideal assessment site but difficult to document. zObjectives delineate what resident should be able to do after completion of rotation. zLearning objectives should span all domains of learning - cognitive, affective, psychomotor

Learning Objectives zReasonable, attainable, and measurable zShould be specific to yClinical setting - inpatient or outpatient yTechnical skills needed - ability to perform the physical exam, injections, EMG’s, surgical procedures

Global Faculty Evaluations zDirectly reflect objectives zBe specific to clinical situations zAdvantages: prolonged observation, direct assessment over time zDisadvantages: “one shot” phenomenon, time consuming, decreasing time with residents due to financial constraints, feedback required, difficult to standardize

Additional Evaluation Methods zMedical record audit yChecklist looking for documentation of specific information yJudgment about decision-making yCan be done longitudinally yRequires substantial faculty time yRecords do not always reflect what happens in patient encounters yImproves documentation but not health care

Computer Simulated Clinical Encounter zComputerized patient management problems zAt best, a partial representation of a complete patient zMust capture key features of interaction zBenefits: exposure to “core” of disorders, consistency, detailed feedback zDisadvantages: cost, time

OSCE zBenefits: consistently display tasks, clinical task scaled to skills needed to be assessed, predetermined grading scale zDisadvantages: LABOR INTENSIVE, costly

Clinical Evaluation Exercise zObserving a trainee obtaining and performing a comprehensive history and physical examination on a new patient yAllowing time to write up case, impression, management plans yPresentation of case with discussion of findings, impressions, recommendations yImmediate feedback to trainee

Mini-Clinical Evaluation Exercise zObservation of focused H&P zDiscussion of diagnosis and Rx plan zEval of performance and feedback zTotal time minutes zMore accurately reflects clinical practice

Mini-CEX z4 areas evaluated yhistory yphysical exam yclinical judgment yhumanistic qualities zRating scale used for evaluation z4-10 needed for reliability - more needed for borderline performers

Mini-CEX zCoupled with oral exam zCould be done at end of each rotation or at end of academic year zReal patients or trained “standardized” patients