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Commentary |
1 Department of Radiology, University of Wisconsin Hospital and Clinics and Medical School, E3/311 Clinical Science Center, 600 Highland Ave., Madison, WI 53792-3252.
Received April 24, 2001;
accepted after revision April 26, 2001.
This article is a commentary on the preceding article by Gunderman.
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To be fully competent practitioners at the completion of their residencies, resident physicians must acquire certain knowledge, skills, and attitudes that are beyond the scope of the clinical educational experiences usually offered by their specialty programs. Therefore, the ACGME has identified a set of topics to which all resident physicians, regardless of specialty, must be exposed during their residencies. This set of topics, referred to as the "core curriculum," includes ethics, socioeconomics, research design, biostatistics, and skills required for critical review of the literature. The ACGME has also determined that by the time they complete their training programs, resident physicians must achieve "general competency" in six domains of clinical practice: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. In an important related action, the American Board of Medical Specialties has agreed that candidates for specialty certification will have to show that they have achieved these general competencies to be certified.
The ACGME Outcome Project (http://www.acgme.org/Outcome/intro.asp) is a long-term initiative by which the ACGME is increasing emphasis on educational outcomes in the accreditation of residency education programs. The current model of accreditation is to assure that programs have established objectives, have an organized curriculum, and evaluate residents and the program. The future envisioned for graduate medical education concentrates more on actual accomplishments of a program through assessment of program outcomes. Programs will be required to develop general and specialty-specific competency-related learning objectives and to identify dependable methods of assessing the achievement of these objectives.
At its September 1999 meeting, the ACGME approved minimum language regarding the general competencies and evaluation process. All residency review committees and institutional review committees must include this minimum language or a variation thereof in their programs or institutional requirements by June 2001. Programs will be held responsible for new requirements related to the six core competencies beginning July 1, 2002.
The ACGME and American Board of Medical Specialties have collaborated on the development of an assessment "toolbox" [2], an online PDF (portable document format) file that can be found at http://www.acgme.org/Outcome/Toolbox.pdf. Included in the toolbox are descriptions of assessment methods that can be used for evaluating residents. In addition to a brief description of each method, there is information pertaining to its use, its psychometric qualities, and its feasibility and practicality. These methods include 360° evaluation (which will be defined in the ensuing text); chart-stimulated recall oral examination; checklist evaluation of live or recorded performance; global rating of live or recorded performance; objective structured clinical examination; procedure, operative, or case logs; patient surveys; portfolios; record review; simulations and models; standardized oral examination; standardized patient examination; and written examination. The commonly used written examination is just one of 13 assessment methods listed. With input from the American Board of Radiology and the Association of Program Directors in Radiology, radiology-specific definitions of the six competencies and how they might be taught and evaluated are currently being developed.
Although resident medical knowledge can be tested with multiple-choice examinations (e.g., the American College of Radiology inservice examination and the American Board of Radiology written examinations), and patient care can be tested with standard checklist evaluation forms after each resident rotation, other competencies are better suited to more creative types of assessment. For example, interpersonal and communication skills might be best evaluated with 360° evaluations, which consist of measurement tools completed by multiple people in a resident's sphere of influence (e.g., program director, other faculty, peers, medical students, nurses, technologists, and patients). These skills can also be assessed by reviewing a resident's radiology reports for evidence of grammatical correctness, accuracy, and conciseness.
Practice-based learning and improvement involves a willingness to learn from errors and to use errors to improve the system or process of care, participation in relevant quality improvement and quality assurance activities, application of evidence-based medicine to planning and interpretation of clinical studies, and making changes in practice and behavior on the basis of faculty assessments and self-assessments of resident performance. These skills might be assessed through attendance at quality assurance and improvement conferences and participation in quality assurance activities such as those associated with mammography accreditation. These skills might be assessed through resident preparation and presentation of case reports using evidence-based medicine. What Dr. Gunderman describes as a need for residents to be more "skeptical and creative" [1] must be complementary to the requirement for trainees to identify and practice best standards of care.
Professionalism refers to sensitivity to patients, families, and colleagues; commitment to ethical principles, particularly confidentiality; proper technique of obtaining informed consent; a responsible work ethic, with particular regard to attendance, personal demeanor, and completion of work assignments; and respect for patients, peers, faculty, and other health care workers. These skills can be evaluated with 360° evaluations, assessment of a resident's attention to work assignments, resident attendance at required educational activities, or resident self-assessment (e.g., case logs related to real-life ethical issues encountered in daily work).
Systems-based practice can be defined as the larger context of the health care system and the ability to effectively call on system resources to provide optimal care. Residents are expected to understand the entire health care system; to be aware of costs, risks, and benefits; and to advocate for quality patient care. Their competence in this area might be assessed by related questions on the American College of Radiology in-service and American Board of Radiology written examinations or by resident participation in the politics of health care.
The movement of the ACGME toward outcomes assessment began in order to hold medical educators accountable for their work. Our system of medical education relies heavily on 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. Measuring program quality by examining structure and process is not a direct or complete measure of the quality of its educational outcomes. Educational outcomes-based data are necessary to inform policy makers and others who have become increasingly focused on issues related to funding for medical education and, most recently, on patient safety.
Dr. Gunderman questions [1],
Do [radiology residents] become more interesting people as a result of their residency experience? Do they become more inquisitive, more creative, or wiser? Or, by inviting them to bury their noses for 4 years in radiology review manuals, are we inviting them to become less interesting, increasingly short-sighted, and more one-dimensional?
He considers residents to be "homogenized" at the end of training.
I see graduating residents as having widely varying interests and talents. Some acquire expertise in a focused area, such as nuclear medicine, and obtain specialized certification by the end of training. Some come to residency after completion of training and practicing in another specialty, such as emergency medicine, and choose to build on this experience during radiology residency and fellowship. Some residents are heavily involved in research. They participate in original laboratory or clinical research projects; author papers published in peer-reviewed journals; receive societal trainee grants and awards; present research at national, regional, and local meetings; and in some cases, go on to pursue a career in academic radiology. I see residents become actively involved in departmental education and quality assurance committees, medical school educational policy committees, and the hospital graduate medical education committee during residency training. Some take an active role in the activities of the state medical society as resident representatives. At the University of Wisconsin, chief residents develop leadership skills through mentoring and leadership courses. The list of examples could go on and on. The point is, residents do not all come out of training with the same knowledge, experience, ability, and interests. However, the American Board of Radiology does assure before granting certification that each resident has attained minimum competency to practice general radiology independently.
Dr. Gunderman says, "The implicit message [to radiology residents] is [that] there are only two types of answers, right answers and wrong answers. Uncertainty is to be avoided at all costs" [1]. I hope this does not describe a uniform atmosphere of learning among training programs. I would also say that those faculty members who are always sure of a diagnosis are sometimes right. Part of what residents must learn is to know their limitations and the limitations of the studies they are interpreting. It is not always possible to be certain.
In addition to the practical approaches offered by Dr. Gunderman [1], I would add that programs should make sure they take advantage of the initiatives of radiology societies for promoting resident involvement in research. Examples include the American Roentgen Ray Society (ARRS)/Radiological Society of North America (RSNA)/Association of University Radiologists (AUR) Introduction to Research Program for second-year radiology residents, the B. Leonard Holman Research Pathway, the RSNA Roentgen Resident/Fellow Research Award, the ARRS Residents in Radiology Award, and numerous specialty society awards and trainee grants.
I agree with Dr. Gunderman [1] if he believes that radiology training should occur in an environment that allows sufficient resident experience in the full range of radiologic examinations, procedures, and interpretations, in which residents learn in an atmosphere free of fear of intimidation or retaliation; are exposed to a regular review of ethical, socioeconomic, medical-legal, and cost-containment issues that affect graduate medical education and medical practice; and receive an appropriate introduction to communication skills and to research design, statistics, and critical review of the literature necessary for acquiring lifelong learning.
Contrary to Dr. Gunderman's conclusion, I do not agree that testing should be secondary; I believe it should be complementary and every bit as important as what we need to learn. Assessment, as part of outcomes-based training, will assure that educators are held accountable for providing the kind of training that will prepare residents to meet individual, patient, and public needs.
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