Competencies and the Competencies and the Ph i i f th F tPh i i f th F tPhysician of the FuturePhysician of the Future

Jeanette Mladenovic, M.D.Jeanette Mladenovic, M.D.Education Grand Rounds Education Grand Rounds

10/0410/04

ObjectivesObjectivesObjectivesObjectives

Competencies in the continuum of physician Competencies in the continuum of physician education.education.

Understanding systemsUnderstanding systems--based practice and based practice and practicepractice--based improvementbased improvement

Challenge the boundaries of our approach to Challenge the boundaries of our approach to medical education. medical education.

THE PATHTHE PATHTHE PATHTHE PATH

CertificationMD Maintenance of Certification ...Certification

The Eight Domains of CompetenceThe Eight Domains of CompetenceSUNY D t tSUNY D t tSUNY, Downstate.SUNY, Downstate.

SUNY Downstate’s domains of competence delineate the attitudes, SUNY Downstate’s domains of competence delineate the attitudes, knowledge and skills that students should possess upon knowledge and skills that students should possess upon

grad ation from this medical school Upon grad ation fromgrad ation from this medical school Upon grad ation fromgraduation from this medical school…Upon graduation from graduation from this medical school…Upon graduation from SUNY Downstate, the student will have demonstrated the SUNY Downstate, the student will have demonstrated the

following:following:

PROFESSIONALISM PROFESSIONALISM A KNOWLEDGE OF BASIC SCIENCE THAT FORMS THE BASIS OF A KNOWLEDGE OF BASIC SCIENCE THAT FORMS THE BASIS OF CLINICAL MEDICINECLINICAL MEDICINEEFFECTIVE COMMUNICATIONEFFECTIVE COMMUNICATIONEFFECTIVE COMMUNICATIONEFFECTIVE COMMUNICATIONBASIC CLINICAL SKILLSBASIC CLINICAL SKILLSAN UNDERSTANDING OF HEALTH MAINTENANCE AND DISEASE AN UNDERSTANDING OF HEALTH MAINTENANCE AND DISEASE PREVENTIONPREVENTIONAN AWARENESS OF HEALTHCARE IN THE CONTEXT OF AN AWARENESS OF HEALTHCARE IN THE CONTEXT OF COMMUNITY AND SOCIETY COMMUNITY AND SOCIETY INFORMATION MANAGEMENTINFORMATION MANAGEMENTA COMMITMENT TO LIFEA COMMITMENT TO LIFE LONG LEARNINGLONG LEARNINGA COMMITMENT TO LIFEA COMMITMENT TO LIFE--LONG LEARNINGLONG LEARNING

CompetencyCompetency--Based Based A dit ti d C tifi tiA dit ti d C tifi ti

ACGME Competencies Certification MOC

Accreditation and CertificationAccreditation and Certification

Medical Knowledge

Professionalism Faculty

Secure Exam

p

Secure Exam

Peer Patient Professionalism

Communication & Interpersonal Skills

Faculty Ratings MiniCEX Logs

Peer-Patient Clinical Skills

License

Patient Care

Interpersonal Skills Logs….. License Appointment

Systems-Based Practice

Practice-Based Learning & Practice

ImprovementPractice

ImprovementgImprovement

Continuum of Clinical SkillsContinuum of Clinical SkillsContinuum of Clinical SkillsContinuum of Clinical Skills

EB therapeutic, diagnostic reasoning

Diagnostic Reasoning

reasoning

g

Data Gathering

Learning the language

Continuum of LearnersContinuum of LearnersContinuum of LearnersContinuum of Learners

Master? Who? ? Who?

Expert

Post GME

Novice

UGE, GME

Lifelong Learning, Assessment and Lifelong Learning, Assessment and Improvement:Improvement:Improvement:Improvement:

Physician CommitmentPhysician Commitment

Fundamental new concept for certification Fundamental new concept for certification d i t f tifi tid i t f tifi tiand maintenance of certificationand maintenance of certification

Habits and skills are learned throughout Habits and skills are learned throughout GMEGME but begin in UGE!but begin in UGE!GME GME -- but begin in UGE!but begin in UGE!Basis for Basis for Continuous Professional Continuous Professional DevelopmentDevelopmentDevelopmentDevelopmentThe professional method for adapting to The professional method for adapting to changechangechangechange

Lessons Learned About CompetenceLessons Learned About CompetenceLessons Learned About CompetenceLessons Learned About Competence

develops along a continuumdevelops along a continuum

Competencedevelops along a continuumdevelops along a continuumis more than knowledge and skillis more than knowledge and skillis more than just knowing the rulesis more than just knowing the rulesis more than just knowing the rulesis more than just knowing the rulesIs a habitIs a habit

Does competence = excellence? Does competence = excellence?

Th h d t i ti i t t i t Th h d t i ti i t t i t The hardest conviction is to get into The hardest conviction is to get into the minds of the beginner that thethe minds of the beginner that theeducation in which he is engagededucation in which he is engaged

is not a college course,is not a college course,g ,g ,not a medical course,not a medical course,

but a life course but a life course but a life course. but a life course.

Sir William OslerSir William OslerSir William OslerSir William Osler

Accountability

ACGME Competencies Courtesy L. Blank

DocumentationDocumentationDocumentation Documentation

WebWeb--based evaluationsbased evaluationsCompetency cards Competency cards Narrative reflectionNarrative reflectionGlobal rating formsGlobal rating formsSemiSemi--annual performance reviewsannual performance reviewsSemiSemi annual performance reviewsannual performance reviewsTrackingTracking

Courtesy L. Blank

The Newest CompetenciesThe Newest Competenciese e est Co pete c ese e est Co pete c es

PracticePractice--based Learning and Improvement:based Learning and Improvement:g pg pResidents are expected to use scientific evidence and methods Residents are expected to use scientific evidence and methods to investigate, evaluate, and improve patient care practices. to investigate, evaluate, and improve patient care practices. (IMWG)(IMWG)(IMWG)(IMWG)

Goals for physician development:Goals for physician development:1. Develop willingness to learn from errors to improve care1. Develop willingness to learn from errors to improve care2. Use Information technology to support decision making2. Use Information technology to support decision making3.3. Identify areas for improvement and implement strategies toIdentify areas for improvement and implement strategies to3. 3. Identify areas for improvement and implement strategies to Identify areas for improvement and implement strategies to enhance knowledge, skills and attitudes, and care processesenhance knowledge, skills and attitudes, and care processes4. Analyze and evaluate practice experiences to continually 4. Analyze and evaluate practice experiences to continually improve quality of care.improve quality of care.improve quality of care.improve quality of care.

Resident CompetencyResident CompetencyResident CompetencyResident Competency

Identify needs within resident’s patientIdentify needs within resident’s patientIdentify needs within resident s patient Identify needs within resident s patient populationpopulationUse measurement to show changes have Use measurement to show changes have ggimproved patient careimproved patient careDemonstrate how to use several cycles of Demonstrate how to use several cycles of yychange to improve care deliverychange to improve care deliveryApply CQI to local population of patients. Apply CQI to local population of patients.

Ogrinc, Academic Medicine, 2003

The Newest CompetenciesThe Newest Competencies --22The Newest Competencies The Newest Competencies 22

Systems Based PracticeSystems Based PracticeResidents are expected to demonstrate an understanding ofResidents are expected to demonstrate an understanding ofResidents are expected to demonstrate an understanding of Residents are expected to demonstrate an understanding of the contexts and systems in which health care is provided, the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and and the ability to apply this knowledge to improve and optimize health care. optimize health care. (IMWG)(IMWG)

Goals for Physician Development: Goals for Physician Development: 1.1. Understand, access, and utilize resources, providers, and Understand, access, and utilize resources, providers, and

systems necessary to provide optimal caresystems necessary to provide optimal caresystems necessary to provide optimal caresystems necessary to provide optimal care2.2. Understand the limitations and opportunities inherent in Understand the limitations and opportunities inherent in

various practice and delivery systems and develop ways to various practice and delivery systems and develop ways to optimize care for the patientoptimize care for the patient

3.3. Apply evidenceApply evidence--based, costbased, cost--conscious strategies for conscious strategies for prevention, diagnosis, and treatmentprevention, diagnosis, and treatment

4.4. Collaborate with other members of the health care team to Collaborate with other members of the health care team to assist patients to deal effectively with complex systemsassist patients to deal effectively with complex systems..ass st pat e ts to dea e ect e y t co p e syste sass st pat e ts to dea e ect e y t co p e syste s

Resident “Competency”: SBPResident “Competency”: SBPResident Competency : SBPResident Competency : SBP

Health care as a system: understand and describe Health care as a system: understand and describe yyreactions of a system perturbed by change initiated reactions of a system perturbed by change initiated by the residentby the resident

Collaboration: contribute to the interdisciplinary Collaboration: contribute to the interdisciplinary efforteffortefforteffort

Social context/accountability: identify community Social context/accountability: identify community resources for quality improvement. resources for quality improvement.

Ogrinc, Academic Medicine, 2003.

Basic Curricula Basic Curricula –– QIQI

IOM’s definition and criteria for quality (STEEPE)IOM’s definition and criteria for quality (STEEPE)IOM s definition and criteria for quality (STEEPE)IOM s definition and criteria for quality (STEEPE)

Understand the rubrics of quality measurement Understand the rubrics of quality measurement q yq y(Donebedian)(Donebedian)

Structure, process, outcomesStructure, process, outcomes

Learn how to apply the following tools:Learn how to apply the following tools:PDSA Flowcharts FMEAPDSA Flowcharts FMEAPDSA, Flowcharts, FMEAPDSA, Flowcharts, FMEAAim and Mission StatementsAim and Mission Statements

IOM Competency ModelIOM Competency Model

Patient-Centered

Care

EvidenceBased

Medicine

Quality Improvement

Informatics

Overlap of Core Competencies for Health Professionals, IOM, 2003

Examples of Systems Based PracticeExamples of Systems Based PracticeExamples of Systems Based PracticeExamples of Systems Based Practice

Anesthesia:Anesthesia: interactive curriculum on SBP in effectiveness of interactive curriculum on SBP in effectiveness of i i h MCQ d f l f db ki i h MCQ d f l f db koperating room, with MCQ and faculty feedbackoperating room, with MCQ and faculty feedback

OBOB--GYN:GYN: Development of standardized orders in L and D for Development of standardized orders in L and D for induction and looking at effectivenessinduction and looking at effectivenessSurgery:Surgery: Turning M and M into a systemsTurning M and M into a systems--based exercise to based exercise to address errorsaddress errorsFamily Medicine:Family Medicine: anonymous selfanonymous self--reporting of errorsreporting of errorsyy yy p gp gInternal Medicine:Internal Medicine: reorganization into firm system; leadership reorganization into firm system; leadership partners rotation. partners rotation. ER:ER: using microsystems model to provide seamless flow ofusing microsystems model to provide seamless flow ofER:ER: using microsystems model to provide seamless flow of using microsystems model to provide seamless flow of chest pain patients. chest pain patients. Common:Common: Aseptic Technique, webAseptic Technique, web--based SBP curricula with based SBP curricula with MCQ; safety curriculaMCQ; safety curriculaMCQ; safety curriculaMCQ; safety curricula

Synpsis, abstracts – ACGME conference, 2004

Practice Improvement Module (PIM)

Collect Chart review Practice reviewPatient surveyData

y

Practice improvementPlan to I

Synthesize and review data

Practice improvement plan

Improve Practice Improvement

Plan

TestTest Change Impact

Reasons for GME workforceReasons for GME workforceReasons for GME workforceReasons for GME workforceReasons for GME workforce Reasons for GME workforce Reasons for GME workforce Reasons for GME workforce

Providers for medically underservedProviders for medically underserved

Hospital incentivesHospital incentives

Enormous cost of replacing residentsEnormous cost of replacing residentsEnormous cost of replacing residentsEnormous cost of replacing residents

Education experiential….

Internal Pressures on the Educational Internal Pressures on the Educational E i tE i tEnvironment Environment

Strained by limited resourcesStrained by limited resources (even in a mission(even in a mission--Strained by limited resourcesStrained by limited resources (even in a mission(even in a missionbased medical school….)based medical school….)

New sights of training, new types of teachersNew sights of training, new types of teachersg g yg g y(..who may or may not get promoted)(..who may or may not get promoted)

New content to meet the changing New content to meet the changing populationpopulation (cultural diversity, geriatrics, ethics, complementary (cultural diversity, geriatrics, ethics, complementary medicine….)medicine….)

N thi kiN thi ki t i tt i tNew thinking: New thinking: competencies not processescompetencies not processes(..just when we figured out the rules..)(..just when we figured out the rules..)

enough to push faculty to their limits……enough to push faculty to their limits…..

External Pressures on the Educational External Pressures on the Educational EnvironmentEnvironment

Changing Mores=

Hours

Increased knowledge=

Greater Complexitylimitations

Greater Complexity

Care changing=

Fewer t diti l

Fiscal Constraint=

Increased productivity

Societal Needs

venuestraditional

venuesproductivity

Concerns

=Safety

Concerns

The Lightbulb…..The Lightbulb…..The Lightbulb…..The Lightbulb…..

There is lessThere is lessThere is less There is less TrainingTraining

Opportunity!!!Opportunity!!!

Our Trainees and Our TrainingOur Trainees and Our Training Programs:

Practice in a high stakes environment

Permit plenty educational dead spacePermit plenty educational dead space

Educate based on what’s available, not whatEducate based on what s available, not whatis needed.

Judge competence by length of time.

…….

“The ringing in your ears?…I think I can help.”“The ringing in your ears?…I think I can help.”

Revolution in Educational NeedsRevolution in Educational NeedsRevolution in Educational NeedsRevolution in Educational Needs

New Curricula (and new skills?)New Curricula (and new skills?)( )( )New Tools for assessment and evaluationNew Tools for assessment and evaluationNew ways to acquire the skills and New ways to acquire the skills and y qy qcompetenciescompetenciesNew ways to maintain our skills and New ways to maintain our skills and

t it icompetenciescompetenciesNew faculty, faculty development, rules for New faculty, faculty development, rules for facultyfacultyfacultyfacultyNew relationships to each otherNew relationships to each otherNew relationships to accrediting bodiesNew relationships to accrediting bodiesNew relationships to accrediting bodiesNew relationships to accrediting bodies

Example: IM of the futureExample: IM of the futureExample: IM of the futureExample: IM of the future

Fosters educational Fosters educational General requirements form General requirements form innovation in expert innovation in expert programs programs Contributes to Contributes to

backbone, remainder open backbone, remainder open to innovation to innovation Requires evaluation of new Requires evaluation of new

armamentarium of tools armamentarium of tools Use outcomes as Use outcomes as measurement ofmeasurement of

qqeducational experienceseducational experiencesProcess requirements Process requirements replaced with outcomesreplaced with outcomesmeasurement of measurement of

competencies.competencies.Education inextricably linked Education inextricably linked to performance improvementto performance improvement

replaced with outcomes replaced with outcomes measuresmeasuresPDs and faculty must PDs and faculty must participate in hospital PIparticipate in hospital PIto performance improvementto performance improvement

Decreases dependency on Decreases dependency on external accrediting bodyexternal accrediting body

participate in hospital PIparticipate in hospital PISite visit infrequent, yearly Site visit infrequent, yearly update report.update report.

New Paradigm for TrainingNew Paradigm for TrainingNew Paradigm for Training New Paradigm for Training

R i i tit ti l it tR i i tit ti l it t1.1. Requires institutional commitmentRequires institutional commitment

2.2. Faculty intensive at some levelFaculty intensive at some level2.2. Faculty intensive at some levelFaculty intensive at some level

3.3. Will Challenge our traditions Will Challenge our traditions

4.4. Will elevate the role of educator in our Will elevate the role of educator in our institutionsinstitutionsinstitutionsinstitutions

Academy of Educators of the FutureAcademy of Educators of the FutureAcademy of Educators of the FutureAcademy of Educators of the Future

Create a culture of support and recognition for Create a culture of support and recognition for pp gpp gmedical education and medical educatorsmedical education and medical educators

Develop a core faculty, who teach, engage inDevelop a core faculty, who teach, engage inDevelop a core faculty, who teach, engage in Develop a core faculty, who teach, engage in curricular innovations and develop new assessment curricular innovations and develop new assessment tools tools

Engage in research in educational outcomes Engage in research in educational outcomes

Foster interdisciplinary sharing: access to ideas, Foster interdisciplinary sharing: access to ideas, tools and faculty to address the common physician tools and faculty to address the common physician competenciescompetenciescompetenciescompetencies

““Remember,Remember,The future isn’t what it used The future isn’t what it used

to be…”to be…”Alias, Yogi Berra