The Core Competencies:

Why, What, and How?

CORD-EM Best Practices in Residency
Training: Reaching for Excellence
February 2003

Pamela L. Dyne, MD Arthur Sanders, MD

Associate Professor of Medicine Professor of Emergency
Medicine
D. Geffen School of Medicine at UCLA
University of Arizona COM
Residency Director
Chair, RRC-EM
UCLA/Olive View-UCLA Emergency
Medicine
 OUTCOMES SHIFT - WHY?
 Accountability - Our system of medical education
relies heavily on considerable public funding. We
therefore need to be accountable to the public in
terms of both meeting public needs and preparing
well-qualified new physicians in the most cost-
effective way possible.
 Process vs. Outcome - Measuring program
quality by examining structure and process is not a
direct or complete measure of the quality of the
educational outcomes of a program.

ACGME
 OUTCOMES SHIFT - WHY?
 Need for Better Measures of Quality -
Availability of educational outcomes-based data
is necessary to inform policymakers and others
who have become increasingly focused on issues
related to funding for medical education, and,
most recently, on patient safety.
 It is incumbent upon us as medical educators to
demonstrate the effectiveness of our educational
programs and to be held accountable for our
work.
ACGME
 QUALITY IMPROVEMENT
 Structure - institution, number of faculty,
patient volume and acuity, number of
procedures, curriculum schedule
 Process - resident shifts and
responsibilities, block rotations,
conference attendance, feedback and
evaluations, teaching methods, etc.
 Outcome - board certification,
successful completion of program, etc.
 ACGME COMPETENCIES
“Minimal Threshold Model” for GME
accreditation

 Minimal processes for education -

curriculum, conferences, patient
populations, procedures, faculty, etc.
 Program has the potential to educate
competent physicians
 ACGME OUTCOMES
Educational Outcomes - “Evidence
showing the degree to which
programs purposes and objectives
are or are not being attained,
including achievement of appropriate
skills and competencies by
students.”

ACGME Outcomes Project

 ACGME COMPETENCIES
 “In the competency-based model …programs
will be asked to show how residents have
achieved competency-based educational
objectives and in turn, how programs use
information drawn from evaluation of those
objectives to improve the educational
experience of the residents. Stated another
way, the minimal threshold model identifies
whether a program has the potential to
educate residents; the competency-based
model examines whether the program is
actually educating them.”
ACGME Outcome Project
 ACGME COMPETENCIES
Competency Based Model

 Educational objectives will need to be

competency based
 How programs evaluate competencies
based on the educational objectives
 How programs use evaluation
information to improve the educational
experience.
IDENTIFYING COMPETENCIES
 Identifying the competencies was stimulated by
increased attention to how adequately physicians
are prepared to practice medicine in the changing
health care delivery system.
 The ACGME derived its general competencies
through a careful study of existing research on
general competencies for physicians. It also
gathered input on the proposed competencies from
various constituencies and stakeholders of GME.
 From this process, the Outcomes Project Advisory
Committee identified six general competencies that
were subsequently endorsed by the ACGME in
February 1999.
ACGME
Program Requirements-draft
Requirements-

Programs must define the specific

knowledge, skills, behaviors, and
attitudes required and provide
educational experiences as needed
in order for their residents to
demonstrate the following:
 The ACGME General
Competencies:
 Patient care
 Medical knowledge
 Practice-based learning and
improvement
 Interpersonal and communication skills
 Professionalism
 Systems-based practice

(What are the competencies for EM?)

 ACGME Assessment
Toolbox
 360° evaluation
 Chart stimulated
recall
 Checklist eval
 Global rating of live or
recorded performance
 OSCE
 Procedure, operative
or case logs
 Patient surveys
 Portfolios
 Record review
 Simulations and
models
 Standardized oral
exam
 Standardized patients
 Written exam (MCQ)
 EMERGENCY MEDICINE
COMPETENCIES
Who defines the specific EM
competencies?
The Model of the Clinical
Practice of Emergency Medicine
RRC-EM Task Force
…and CORD-EM is at the table
“The ACGME Core Competencies:
Getting Ahead of the Curve”
CORD-EM, March 2002

Academic Emergency Medicine,

November 2002, Vol. 9, No.11
 Patient Care: Goals
 ACGME: “Residents must be able to
provide patient care that is effective,
appropriate, and compassionate for the
treatment of health problems and
promotion of health.”
 CORD: “EM residents must be able to
provide patient care that is timely,
effective, appropriate, and compassionate
for the management of health problems
and promotion of health.”
King, Schiavone, Counselman, Panecek, Patient Care Competency in
Emergency Medicine Graduate Medical Education: Results of a Consensus
Group on Patient Care. AEM 2002;9:1227-1235
EM Patient Care: Objectives
a. Gather accurate, essential information in a
timely manner from all sources, including
medical interviews, physical examinations, out-
of-hospital care personnel, medical records,
and diagnostic/therapeutic procedures.
b. Integrate diagnostic information and generate
an appropriate differential diagnosis.
c. Implement an effective patient management
plan including therapy, appropriate
consultation, disposition, and pt. education
EM Patient Care: Objectives
a. Competently perform the
diagnostic and therapeutic
procedures and emergency
stabilization considered essential
to the practice of EM.
b. Demonstrate the ability to
appropriately prioritize and stabilize
multiple patients and perform other
responsibilities simultaneously.
 EM Patient Care: Assessment
ChecklistEvaluation of Live
Performance (Direct Observation):
 “Snapshot” approach using on-shift
attending and repeated isolated mini-evals
 Comprehensive approach involving a non-on-
shift faculty member for several hours at a
time

+Advantages: real clinical environment, time efficient

for residents and faculty (potentially)
-Concerns: Hawthorne effect, observer training bias,
disturbance of physician-patient relationship
EM Patient Care: Assessment
• Simulations and Models with D.O.
procedures and stabilization

 Secondary methods:
ALL toolbox items relevant; patient
surveys, record review, 360° eval, and
procedure logs limited applicability
 Medical Knowledge: Goals
 ACGME: “Residents must demonstrate
knowledge about established and
evolving biomedical, clinical, and
cognate (eg. epidemiological and social-
behavioral) sciences and the application
of this knowledge to patient care.”
EM Medical Knowledge: Goals
 CORD-EM: “Residents are expected to
formulate an appropriate DDx with
special attention to life-threatening
conditions, demonstrate the ability to
utilize available medical resources
effectively and concurrent with patient
care, and apply this knowledge to
clinical problem solving and clinical
decision-making.”
Wagner, MJ, Thomas, HA, Application of the Medical Knowledge General
Competency to Emergency Medicine, AEM 2002;9:1236-1241
 EM Medical Knowledge:
Objectives
a. Identify life threatening conditions
b. Identify the most likely diagnosis
c. Synthesize acquired patient data
d. Identify how and when to access current
medical information
e. Properly sequence critical actions in patient
care
f. Generate a DDx for an undifferentiated
patient
g. Complete disposition of patients using
available resources
 EM Medical Knowledge:
Assessment
 Checklist Evaluation of Live Performance
(Direct Observation):
 Progressive questioning by on-shift attending
Beyond the usual applied questions
Content area specific approach

 Comprehensive approach involving a non-on-

shift faculty member for several hours at a
time
Structured clinical assessment
 EM Medical Knowledge:
Assessment
 Objective standardized examination (OSE)
 National In-Service exam
 Locally written tests
 Topic specific modular curriculum with exams
 Computer-based learning modules with exams

+Advantages: objective, criterion referenced, prep for “the

real thing,” easy to track and provide data to RRC

−Concerns: labor and time intensive, (external locus of

control for learning may not promote development of
career learning habits)
 EM Medical Knowledge:
Assessment
 Simulations and models
 Procedures and low-frequency, critical content
areas
 OSCE, SP, computer models
 Needs objective evaluation tool development
 Classroom observation Inconsistencies
knowledge?
in style vs.

 Chart-stimulated recall needs scoring protocol

 Global rating form less precise, halo vs. millstone effect
 360° eval TNTC confounders
 portfolios ? for remediation
 Practice-Based Learning and
Improvement: Goals

 ACGME: “Residents must be able to

investigate and evaluate their patient
care practices, appraise and
assimilate scientific evidence, and
improve their patient care practices.”
 EM Practice-Based Learning
and Improvement: Objectives
A. Analyze and assess your practice
experience and perform practice-based
improvement.
 Locate, appraise, and utilize scientific
evidence related to your patient’s health
problems and the larger population from
which they are drawn.
 Apply knowledge of study design and
statistical methods to critically appraise
medical literature.
Hayden, SR, Dufel, S, Shih, R, Definitions and Competencies for
Practice-based learning and improvement, AEM 2002;9:1242-1248
 EM Practice-Based Learning
and Improvement: Objectives

 Utilize information technology to

enhance your education and
improve patient care.
 Facilitate the learning of students,
colleagues, and other health care
professionals in emergency
medicine principles and practice.
 EM Practice-Based Learning
and Improvement: Assessment
QA projects, individual learning plans, journal
 Portfolio club write-ups, etc…self-reflection of learning
and how their EM practice might change as a
result
 CSR Focus on decision-making, test interpretation,
rationale for diagnostic and therapeutic
interventions; “educational prescription”

 360° global eval

frequency, efficiency, and utilization of evidence in
clinical decision-making; lectures, bedside teaching
 Computer simulation
Web-based modules requiring searching, analyzing medical info
resources; monitoring software to automatically record computer
sessions
 Interpersonal and
Communication Skills: Goals
 ACGME: “Residents must be able to
demonstrate interpersonal and
communication skills that result in
effective information exchange and
teaming with patients, their families,
and professional associates.”
 EM Interpersonal and
Communication Skills: Objectives
a. Demonstrate the ability to respectfully,
effectively, and efficiently develop a therapeutic
relationship with patients and their families
b. Demonstrate respect for diversity and cultural,
ethnic, spiritual, emotional, and age-specific
differences in patients and other members of the
health care team.
c. Demonstrate effective listening skills and be able
to elicit and provide information using verbal,
nonverbal, written, and technological skills.
Hobgood, Riviello, Jouriles, Hamilton, Assessment of Communication and
Interpersonal Skills Competencies. AEM 2002;9:1257-1269
 EM Interpersonal and
Communication Skills:Objectives
a. Demonstrate ability to develop flexible
communication strategies and be able to adjust
them based on the clinical situation
b. Demonstrate effective participation in and
leadership of the health care team
c. Demonstrate ability to elicit patient’s motivation for
seeking health care
d. Demonstrate ability to negotiate as well as resolve
conflicts
e. Demonstrate effective written communication skills
with other providers and to effectively summarize
for the patient upon discharge
 EM Interpersonal and
Communication Skills:Objectives
a. Demonstrate ability to effectively use the
feedback provided by others
b. Demonstrate ability to handle situations
unique to EM:
Intoxicated patients High-risk refusal of care
AMS patients
Delivering bad news Communication with out-
of-hospital personnel and
Difficulties with non-medical personnel
consultants
Acutely psychotic patients
DNR/end-of-life decisions
Disaster medicine
Patients with
communications barriers
 EM Interpersonal and
Communication
Skills:Assessment
 Direct Observation (D.O.)
+on-shift or not-on-shift attending; direct feedback
-expensive faculty time, Hawthorne effect, disrupts
doc/pt relationship, lack of objective measures
 Standardized Patients (SP)
practice low-frequency/high stakes events
(death telling)
 simulations
and models, OSCE, CSR,
standardized oral examinations
especially for conflict resolution and consultations
 Professionalism: Goals
 ACGME: “Residents must
demonstrate a commitment to
carrying out professional
responsibilities, adherence to ethical
principles, and sensitivity to a
diverse patient population.”
 EM Professionalism:
Model Behaviors
 Arrives on time and prepared to work
 Appropriate (inoffensive) dress and cleanliness
 Willingly sees patients throughout the entire shift
 Appropriate sign-outs, both giving and receiving
 Observable patient advocacy in disposition
 Appropriate use of symptomatic care
 Completes medical records honestly and
punctually
 Treats patients/families/staff/paraprofessional
personnel with respect

Larkin, Binder, Houry, Adams, Defining and evaluating professionalism:

A core competency for graduate emergency medical education. AEM
2002;9:1249-1256
 EM Professionalism:
Model Behaviors
 Protects staff/family/patient’s interests/confidentiality
 Demonstrates sensitivity to patient’s pain, emotional
state, and gender/ethnicity issues
 Actively seeks feedback and immediately self-corrects
 Shakes hands with the patient and introduces himself
or herself to the patient and family
 Effectively coordinates team
 Unconditional positive regard for the patient, family,
staff, and consultants
 Accepts responsibility/accountability
 Recognizes the influence of marketing and advertising
 EM Professionalism:
Model Behaviors
 Open/responsive to input/feedback of
other team members, patients, families,
and peers
 Uses humor/language appropriately
 Discusses death honestly, sensitively,
patiently, and compassionately
 Participates in peer-review process
 Fairness in recruitment of residents,
faculty, and staff
 EM Professionalism:
Assessment
 Knowledge and awareness of
professional norms and behavior
written testing
detached from clinical setting
 Moral
reasoning and professional
capacity
simulations: OSCE, computerized, oral exams, SPs
??? Gender bias in approach: justice vs. care
 Professional behavior
D.O.; 360° global eval; SPs
Systems-Based Practice: Goals
 ACGME: “Residents must demonstrate an
awareness of and responsiveness to the larger
context and system of health care and the ability
to effectively call on system resources to provide
care that is of optimal value.”
 CORD-EM: “ EM Residents must demonstrate an
awareness of health care systems and the ability
to effectively mobilize system resources to
provide optimal care.”

Dyne, PL, Strauss, RW, Rinnert, S, Systems-based practice: The sixth core
competency. AEM 2002;9:1270-1277
EM Systems-Based Practice:
Objectives
 Understand, access, appropriately utilize,
and evaluate the effectiveness of the
resources, providers, and systems
necessary to provide optimal emergency
care.
 Understand the different medical practice
models and delivery systems and how to
best utilize them to care for the individual
patient.
EM Systems-Based Practice:
Objectives
 Practicecost-effective health care
and resource allocation that does not
compromise quality care.
 Advocate for and facilitate patients’
advancement through the health care
system.
EM Systems-Based Practice:
Assessment
 Portfolios
 Requires resident self-reflection
content selection; establishes a pattern for
continued life-long learning
 Inclusion items for SBP: admin/QA
project, relevant scholarly project,
patient care example, etc.
 Evaluation of success: standardized vs.
based on the educational process
faculty development:“teach the teacher”
EM Systems-Based Practice:
Assessment
 Direct Observation (D.O.)
especially for multitasking and team-management
 Global rating
assessment instrument needs development

 360° evals
takes advantage of peer pressure, very labor
intensive
 Standardized oral exams
modify existing format to include SBP content
 What should CORD do?
 Develop
validated and reliable
assessment instruments
 Validated checklist of live performance
 New simulators and/or computer-based
interactive programs
 Validated portfolio assessment
 Attention to low-frequency but critical skills
assessment
 Focus on faculty development
 “Teach from the middle”
 WHAT SHOULD
PROGRAMS DO?
 Begin the think in terms of competencies
 Evaluate ACGME toolbox for assessment
 Educational faculty retreats

 Develop measurable learning objectives

 Assess tools for measuring objectives

 DO NOT DO NOTHING
 OUTCOME QUESTIONS
 Do the residents achieve the learning objectives
set by the program?

 Whatevidence can the program provide that it

does so?

 Howdoes the program demonstrate continuous

improvement in its educational processes?
 Transforming the
Accreditation Process
 Theshift from emphasis on structure-
and-process components to emphasis
on outcomes will be a gradual
transition. The need for programs to
provide evidence of structures and
processes will not disappear but will
gradually become less critical to the
overall accreditation process.