The Competencies
Erica S. Friedman MD
Medicine: A Competency-Based Companion is part of a series for medical students and residents designed to guide you through an expert clinician’s thought process when encountering a particular patient or clinical problem; it uses a competency-based framework to approach the problem.
Competencies are an educational paradigm helpful in clarifying for the teacher and the learner the outcomes-based performance expectations. Competencies identify behaviors as opposed to knowledge or skills, and they require synthesis and integration of information to achieve the outcome. They define what physicians must be able to achieve for effective practice and to meet the needs of their patients. Defining competencies also helps guide curriculum development, teaching, learning, and assessment.
Medical education has experienced a major paradigm shift from structure- and process-based to competency-based education and measurement of outcomes. Structure- and process-based education focuses on knowledge acquisition in a fixed time frame, has the teacher responsible for the content and dissemination of knowledge, and, in general, evaluates success by defining the norm and failing anyone whose performance falls more than two standard deviations below the mean. In contrast, competency-based education focuses on knowledge application, and the learner is the driving force for the process, equally responsible with the teacher for the content. It utilizes multiple evaluations in real time and, in general, applies a standard for developing the criteria for competence. It allows and expects variability in time for mastery of these competencies.
In the latter part of the 20th century, the public expectation for accountability and responsibility around physician competency became a driving force for the Accreditation Council for Graduate Medical Education (ACGME) to establish the competencies. The ACGME shifted its focus from a structure and process system of graduate medical education to one that is outcomes-based and since 1999 has required all residents in training to achieve competence in six broad domains.
The ACGME’s six core competencies are as follows:
6. Systems-Based Practice. Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.*
These six competencies are intentionally general, because it is expected that each residency will define the specific knowledge, skills, and attitudes required to meet these competencies in that specific specialty.
Being an exemplary physician requires more than knowing how to diagnose and manage patients. It requires a constellation of skills, attitudes, and abilities that include the ability to communicate effectively, understand and embody the expectations of the profession, and use the literature in an evidence-based fashion to improve patient care and outcomes, as well as to evaluate one’s own practice.
Organizing this book around the competencies is novel and assists the learner in developing clinical reasoning and in understanding the required competencies for each patient care scenario. The chapters are structured around a case presentation leading to an explanation of the preliminary differential diagnoses, why specific information is relevant (history, physical exam, and diagnostic testing) and should be collected, and how to interpret this information so as to decide upon a patient diagnosis. Each chapter provides a discussion of the presentation and key diagnostic features of each possible diagnosis, the underlying pathophysiology, and general concepts around management. This part of each chapter addresses the ACGME Medical Knowledge and Patient Care competencies. Each chapter then addresses the requisite Interpersonal and Communication Skills to care for the patient, and identifies a Professionalism issue from the Advancing Medical Professionalism to Improve Health Care (ABIM) professionalism principles charter that is relevant to the case. It also provides best evidence around a patient care issue (Practice-Based Learning and Improvement), and identifies and discusses a Systems-Based Practice issue that impacts on the care of the patient.
Most medical student educational materials provide information on medical knowledge and patient care. This resource goes further in identifying what issues relate to systems-based practice and practice-based learning. It also concisely provides an explanation for the reasoning behind potential diagnoses and helps prioritize them based upon the key features of each one. In short, it is the equivalent of a functional magnetic resonance imaging scan, providing a road map of the path of an expert’s diagnostic reasoning.
It is exceedingly helpful for medical students and residents to approach taking care of patients using a competency-based framework in preparation for directing their learning both during medical school and residency training and beyond, and this resource supports development of the skills required for development of an exemplary physician.
Competency definitions according to the ACGME are provided in Appendix 1 to this section.
*From ACGME Competency definitions: Used with permission of Accreditation Counsel for Graduate Medical Education © ACGME 2011. Please see the ACGME website: www.acgme.org for the most current version.
