Portal de Periódicos da CAPES

Milestones and Competency-Based Medical Education

2013; Elsevier BV; Volume: 145; Issue: 5 Linguagem: Inglês

10.1053/j.gastro.2013.09.029

1528-0012

William Iobst, Kelly J. Caverzagie,

Health and Medical Research Impacts

In times of change, learners inherit the earth while the learned find themselves beautifully equipped to deal with a world that no longer exists.—Eric Hoffer Competency-based medical education (CBME) is quickly moving from theory to reality for subspecialty fellowship training. With the launch of the Accreditation Council for Graduate Medical Education's (ACGME) Next Accreditation System (NAS)1Nasca T.J. Philibert I. Brigham T. et al.The next GME accreditation system—rationale and benefits.N Engl J Med. 2012; 366: 1051-1056Crossref PubMed Scopus (1030) Google Scholar in July 2013, allopathic graduate medical education training programs accredited by the ACGME must use competency-based training to demonstrate that trainees have attained the knowledge, skills, and attitudes required for the practice of safe and effective unsupervised practice. Although new to many subspecialty program directors and faculty, CBME is not necessarily a new concept.2Carraccio C. Wolfsthal S.D. Englander R. et al.Shifting paradigms: from Flexner to competencies.Acad Med. 2002; 77: 361-367Crossref PubMed Scopus (600) Google Scholar The ACGME began the transition to CBME with the initiation of the Outcomes Project in 1997.3Sullivan G. Simpson D. Cooney T. et al.A milestone in the milestones movement: the JGME Milestones Supplement.J Grad Med Educ Suppl. 2013; 5: 1-4Crossref PubMed Google Scholar Although the Outcomes Project proved helpful at introducing important terms and concepts, programs struggled with implementing competency-based assessment and evaluation of trainees using this framework.4Swing S.R. The ACGME outcome project: retrospective and prospective.Med Teach. 2007; 29: 648-654Crossref PubMed Scopus (549) Google Scholar Recognizing this barrier, the ACGME called for the development and eventual implementation of specialty-specific developmental milestones to describe the progression of competence in the 6 general competencies5Nasca T.J. The next step in the outcomes-based accreditation project.ACGME Bulletin. 2008; : 2-4Google Scholar (Figure 1). With the launch of the NAS in 2013, milestones reporting was formalized as 1 of 9 key performance indicators that will be used by the ACGME to determine a programs accreditation status.1Nasca T.J. Philibert I. Brigham T. et al.The next GME accreditation system—rationale and benefits.N Engl J Med. 2012; 366: 1051-1056Crossref PubMed Scopus (1030) Google Scholar In early 2013, the Internal Medicine community completed the work of writing these milestones.6Caverzagie K.J. Iobst W.F. Aagaard E.M. et al.The internal medicine reporting milestones and the Next Accreditation System.Ann Intern Med. 2013; 158: 557-559Crossref PubMed Scopus (52) Google Scholar The Internal Medicine subspecialties are now charged with developing similar milestones by early 2014. This article reviews important concepts relating to CBME and the development of milestones for Internal Medicine and its associated subspecialties. To effectively assess and evaluate trainees using milestones, subspecialty training program directors and faculty must first understand a number of basic definitions and principles of CBME. Described by Caverzagie as "competenglish," negotiating this new lexicon requires defining CBME and an understanding of the key terms of competency, competent, and competence.7Caverzagie KJ. Making milestones matter: capturing what you already do. PowerPoint presentation, Association of Program Directors of Internal Medicine, Spring Education Precourse, Las Vegas, NV, April 10, 2011.Google Scholar CBME is defined as "an outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies."8Frank J.R. Snell L.S. Cate O.T. et al.Competency-based medical education: theory to practice.Med Teach. 2010; 32: 638-645Crossref PubMed Scopus (1085) Google Scholar For ACGME-accredited programs, like those in gastroenterology and transplant hepatology, this organizing framework is the 6 general competencies listed in Figure 1.4Swing S.R. The ACGME outcome project: retrospective and prospective.Med Teach. 2007; 29: 648-654Crossref PubMed Scopus (549) Google Scholar The outcome is a physician workforce capable of delivering safe, effective, unsupervised medical care that meets the needs of our complex and evolving health care system.9Frenk J. Chen L. Bhutta Z.A. et al.Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.Lancet. 2010; 376: 1923-1958Abstract Full Text Full Text PDF PubMed Scopus (2890) Google Scholar The Institute for Healthcare Improvement Triple Aim Initiative10Berwick D.M. Nolan T.W. Whittington J. The triple aim: care, health, and cost.Health Aff. 2008; 27: 759-769Crossref PubMed Scopus (3205) Google Scholar and the Institute of Medicine definition of high-quality care11US Institute of MedicineCommittee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. National Academies Press, Washington, DC2001Google Scholar provide examples of this outcome. Competency is defined as "an observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes."8Frank J.R. Snell L.S. Cate O.T. et al.Competency-based medical education: theory to practice.Med Teach. 2010; 32: 638-645Crossref PubMed Scopus (1085) Google Scholar Not to be confused with the ACGME general competencies, which are the broad and overarching organizing framework of the NAS, this definition focuses on the specific abilities expected of the individual physician. For gastroenterology, completing a colonoscopy is an example of such a competency. To be judged competent requires that the trainee possess all the required abilities being assessed in a certain context at a defined stage of education or practice.8Frank J.R. Snell L.S. Cate O.T. et al.Competency-based medical education: theory to practice.Med Teach. 2010; 32: 638-645Crossref PubMed Scopus (1085) Google Scholar In the current example, a fellow in the second year of training may be deemed competent to independently perform a routine or straightforward colonoscopy by having been observed successfully completing this procedure multiple times. However, this designation of competent performance is limited to straightforward colonoscopy and cannot be extended to include a more complicated colonoscopy that requires complex manual skills, such as a high-risk biopsy. Such a designation would require that the trainee be observed competently completing colonoscopy under those circumstances. Finally, competence entails more than the discrete demonstration(s) of competent behavior at a specific time and place; it requires that the individual apply those abilities appropriately in routine clinical practice to achieve optimal results.12ten Cate T.J.O. Snell L. Carraccio C. Medical competence: the interplay between individual ability and the health care environment.Med Teach. 2010; 32: 669-675Crossref PubMed Scopus (213) Google Scholar To have competence performing a colonoscopy, the trainee must consistently demonstrate competent behavior in a variety of clinical situations and environments. This requires the program director and faculty to observe enough examples of competent performance to attest that the trainee can safely and effectively perform colonoscopy in future, as yet undefined clinical settings. In a competency-based system, training programs must be confident (know) that trainees have demonstrated the necessary competence to advance in training or to proceed to the next stages of their careers. Milestones facilitate this determination by providing a roadmap for programs and trainees that describes the development of competence. Reflecting the evolving nature of CBME and specifically the milestones work, it is important to recognize that internal medicine has 2 sets of distinct yet complimentary milestones documents—curricular milestones and reporting milestones. The curricular milestones, published in 2009, describe 142 discrete, observable behaviors that define the developmental progression of specific knowledge, skills, and attitudes within each of the 6 general competencies that culminate in the description of a proficient trainee.13Green M.L. Aagaard E.M. Caverzagie K.J. et al.Charting the road to competence: developmental milestones for internal medicine residency training.J Grad Med Educ. 2009; 1: 5-20Crossref PubMed Google Scholar Figure 2 provides an example of 3 curricular milestones for the ACGME general competency Patient Care that address the specific skill of historical data gathering. Although proving invaluable to curriculum development and for providing feedback to trainees, these milestones proved too numerous and granular for attesting to the high-level competence needed to deliver safe and effective unsupervised medical care. Recognizing this gap, the internal medicine education community developed the Internal Medicine Reporting Milestones.6Caverzagie K.J. Iobst W.F. Aagaard E.M. et al.The internal medicine reporting milestones and the Next Accreditation System.Ann Intern Med. 2013; 158: 557-559Crossref PubMed Scopus (52) Google Scholar Released in January 2013, the reporting milestones are written as narrative statements that describe the development of competence in a learner.14Iobst W. Aagaard E. Bazari H. et al.Internal Medicine Milestones.J Grad Med Educ Suppl. 2013; 5: 14-23Crossref PubMed Google Scholar They are organized into 22 subcompetencies that describe high-level, synthetic learner stages in each of the 6 ACGME general competencies. The reporting milestones are written to be context free; they describe the learner regardless of the learning venue, program, or level of learner. As written, they allow an evaluator to judge a trainees' performance against an expected outcome (ie, specific milestones in a subcompetency rather than against peers or numbers on an artificial scale). Rating trainees using narrative descriptions improves interrater reliability and also reduces range restriction by facilitating the use of the entire range of descriptions.15Thomas M.R. Beckman T.J. Mauck K.F. et al.Group assessments of resident physicians improve reliability and decrease halo error.J Gen Intern Med. 2011; 26: 759-764Crossref PubMed Scopus (18) Google Scholar Figure 3 provides an example of the reporting milestones for the subcompetency, "Requests and provides consultative care." Each subcompetency begins on the left-hand side with ≥1 critical deficiencies (ie, absence of development toward competence) followed by narrative descriptions of a learner as he/she develops competence for that particular subcompetency. Continuing toward the right, each subcompetency also identifies a profile of milestones that describe competence for unsupervised practice and concludes with a column of milestones that define aspirational outcomes. Although separate from the curricular milestones, the reporting milestones were developed using the curricular milestones as a template. As a result, the curricular milestones provide specific content that can be used to develop meaningful assessments and, overall, help to inform the development of competence and reporting of outcomes via the NAS. Moving forward, each subspecialty of internal medicine will need to develop reporting milestones that define the development of competence for that specialty. This work started in early 2013 with the understanding that ACGME will incorporate subspecialty milestones data into accreditation standards when this work has been completed and is ready for use in the accreditation process. The work of developing these milestones for gastroenterology is actively underway with leaders of multiple gastroenterology specialty societies participating in a larger working group of all internal medicine subspecialty societies convened by the ACGME, the American Board of Internal Medicine, and the Alliance for Academic Internal Medicine. During the second half of 2013, this working group will develop a draft set of common subspecialty milestones by modifying the internal medicine reporting milestones to more appropriately assess competence for fellowship training. Particular attention will be given to defining milestones specifically for scholarly activity. Participants will also consider whether or not subspecialty curricular milestones should be developed for the purposes of developing appropriate curricula and assessment systems. By providing a standard framework and language for attesting to the competence of all trainees, milestones represent an important and necessary step in the transition to a competency-based system of graduate medical education. Potential benefits of CBME and milestones development include:•Clearly defined performance expectations of trainees including frameworks for self-assessment, self-directed learning, and robust, specific feedback;•Curricular guides that align training outcomes with societal needs;•Frameworks for better assessment and evaluation of competence with the enhanced ability to identify and facilitate learning for trainees struggling to demonstrate competence as well as those who are performing well; and•The ability for our profession, including accreditation and certification bodies, to articulate to external stakeholders the expected outcome of training. The transition to CBME will require significant redesign of graduate medical education. In fact, the Carnegie Foundation has called for the establishment of rigorous and progressively greater levels of competency across the full continuum of medical education.16Irby D.M. Cooke M. O'Brien B.C. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010.Acad Med. 2010; 85: 220Crossref PubMed Scopus (508) Google Scholar Defining subspecialty milestones is only a first step in the ongoing redesign required to achieve the full potential of CBME. Additional work includes the:•Study of the subspecialty milestones to ensure that they describe the developmental progression toward competence and that they measure the desired outcomes of physicians who are capable of meeting the needs of our evolving health delivery system;•Demonstration that the "ready for unsupervised practice" milestones are achievable and accurately describe the successful transition from residency or fellowship training to unsupervised practice;•Development of assessment systems that generate the data required to accurately identify each trainees progression toward competence in the reporting milestone;•Faculty development initiatives designed to train faculty to effectively teach and assess trainees; and•National re-engineering of the graduate medical education system to appropriately align funding streams and program structures to support the requirements of a competency-based education system. Rarely does the opportunity to create meaningful change present itself. Over 100 years ago, medical schools embraced such an opportunity and created a system of undergraduate medical education that exists to this day. The graduate medical education community now finds itself facing such an opportunity. If the promise of the NAS is to be achieved, we must embrace this opportunity and the hard work it requires. Defining the continuum of competency across GME and ultimately across the professional life of a physician is a necessary first step in this process. Are we willing to embrace this opportunity?