Competency-based residency education: I'm from Missouri--show me!

How many of us with extensive experience educating residents have, over the years, run across a resident who didn't quite measure up but somehow made it through the training program? If you have educated enough residents, you will doubtless recognize this unsettling phenomenon. Perhaps you have encountered a resident with only a marginal knowledge base or one who displayed a striking lack of professional behavior. Perhaps you have met a resident who performed brilliantly on standardized examinations but was unable to gather and synthesize real patient data and develop a plan. Perhaps you have worked with a resident who was a stellar surgical technician but alienated every patient and colleague with whom he or she came into contact. It is more than likely that you have been frustrated at the residency program's seeming inability to remediate (or even identify) these residents or, if irremediable, to terminate them. What are we to do?

Several years ago, the Accreditation Council for Graduate Medical Education (ACGME) asked itself the same question. In 1999, it launched its response: the ACGME Outcome Project. (1) The Outcome Project is a major, long-term educational initiative that has completely changed the landscape of residency education. Through it, the ACGME has put forth the audacious proposal that graduate medical education (GME), like clinical medicine, can be subjected to rigorous evaluation. It has demanded that residency programs apply to the training of residents the basic principles of quality assurance used on a daily basis in clinical practice.

The Outcome Project rests on theACGME's Six General Competencies. These are the six areas of performance in which each resident in every specialty must now demonstrate competence prior to graduation. They are: medical knowledge, patient care, practice-based learning and improvement, interpersonal skills and communication, professionalism, and systems-based practice. These Six General Competencies, tailored to each specialty, must be incorporated into the learning goals and objectives of each residency program. Each residency program must then develop evaluation methods to assess the goals and objectives it has developed. Finally, each residency program must then "close the loop" by using the data from its resident evaluation processes to determine whether its educational program enables its residents to meet the goals and objectives that the program has articulated. The Outcome Project ensures that programs invest time and energy in educational outcome more than in educational process.

What does this have to do with quality assurance? The analogy is an apt one. In quality assurance in the clinical setting, we first identify those clinical outcomes that we wish to measure and that we feel represent quality of care. In the GME model, these outcomes are represented by the Six General Competencies. We then decide exactly how we are going to measure these clinical outcomes; in GME, our evaluation processes are the means by which we measure our educational outcomes. Next, we compare our outcomes with accepted benchmarks, either national or local, to see whether we have met our standards; in GME, our benchmarks are the learning goals and objectives of the residency program. Finally, in both models, we decide whether there is a performance gap between our actual outcomes and our benchmarks. If a performance gap exists, we go back and examine our processes to see how we can improve our outcomes.

The ACGME Outcome Project has completely changed the paradigm of resident education. Residency accreditation used to be process oriented; the Residency Review Committees (RRCs) were interested in how a residency was run. The only outcome that was seriously considered was the rate of board certification; although a valuable statistic, it is "a day late and a dollar short," because any resident who fails is already out of our hands. The accreditation process is now outcome oriented; although still interested in ensuring that a residency program has the educational infrastructure in place to train physicians, the RRCs are now all "from Missouri"--they want us to show them through our evaluation processes that each resident is competent in all Six General Competencies prior to graduation, and that we use our resident evaluation data to improve continuously the quality of our educational programs.

Since the inception and implementation of the Outcome Project, there has been an explosion of research into the best ways to teach and evaluate residents. Although we are still in the early stages of this process, a great deal of valuable material has been developed to help us teach, assess, and remediate when necessary, residents whom we train to take care of the public. Indeed, this was the motivating factor behind the ACGME's decision to completely change the way we approach graduate medical education--to help us honor the sacred trust placed upon us by enabling us to ensure that every physician we send out to care for the public is completely competent to practice medicine.

Reference

(1.) ACGME Web site, accessed December 30, 2004; www.acgme.org.

CYNTHIA G. SILBER, MD, FACOG Associate Dean for Graduate Medical Education Jefferson Medical College Thomas Jefferson University