Copyright Hershey S. Bell, MD 2002 Strategies for Teaching and Integrating the New Competencies into...

Copyright Hershey S. Bell, MD 2002

Strategies for Teaching and Integrating the New Competencies

into Your Curriculum

Strategies for Teaching and Integrating the New Competencies

into Your Curriculum

A Call For Action

Hershey S. Bell, MD, FAAFPA Call For Action

Hershey S. Bell, MD, FAAFP


PhilosophyPhilosophy

A system of beliefs and principles that guide questions, answers,

decisions and actions


Proposed Philosophy for Medical Education

Proposed Philosophy for Medical Education

• The intent and outcome of Medical Education should be clear to all involved

• Every learner and teacher within Medical Education should be clear on their accountability in the system

• Medical Education should foster the development of effective relationships

• Medical Education should be safe for all those involved


Competency-Based EducationCompetency-Based Education

• Provides clarity of learning direction for both faculty and residents

• Creates accountability around the process and outcomes of learning

• Requires relationship-based teacher/learner interaction

• Provides an opportunity for added safety in education


CarrollCarroll

Re-defined aptitude as the time that it takes to achieve competency

AptitudeAptitude


BloomBloom

Suggested that if Carroll’s notion of aptitude is correct, then it must be theoretically possible to manipulate the learning environment such that

every student can achieve competency given enough time.


Competency Based EducationCompetency Based Education

Competencies

Instruction

Formative Evaluation

Remediation

Educational Dx and Rx


CompetencyCompetency

The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning,

emotions, values, and reflection in daily practice for the benefit of the individual and the community

being served.

Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002


DefinitionsDefinitions

• Competency– The minimum level required to practice one’s

craft

• Mastery– A pursuit of excellence above and beyond

competence (Dreyfus Model)


Competency and MasteryCompetency and Mastery

Competency

The Road to MasteryStart


CLARITYCLARITY


Validation for the STFM Competencies

Validation for the STFM Competencies

• Bauer, Jonas, Cass and Bell, 1989

• Literature Review

• STFM Task Force on Competency-Based Education, 1992-1997– Focus Groups– Delphi Panels

• Hunterdon Medical Center Faculty, 1989-1996


STFM Task Force on Competency-Based Education

STFM Task Force on Competency-Based Education

• 5 Realms of Competency– Clinical Acumen (CA), Interpersonal Skills (IS),

Organizational Skills (OS), Business Practice (BP), Growth and Development (GD)

• Integrated Competency Paradigm– Teaching can occur in any realm, or in any combination

of realms and be of value

Bell HS, Kozakowski SM, Winter RO. Competency-based education in family practice. Fam Med 1997;29(10):701-4


The Integrated Competency ModelThe Integrated Competency Model

GD

OS BP

IS CA


Competencies for the Emerging Practice Environment

Competencies for the Emerging Practice Environment

• Health care system overview

• Population-based care

• Quality measurement and improvement

• Medical Management

• Preventive Care

• Physician-Patient Communication

• Ethics

• Teamwork and Collaboration

• Information management and technology

• Practice Management

Halpern R, Lee MY, Boulter PR, Phillips RR. Academic Medicine 2001


ACGME General CompetenciesACGME General Competencies

• Patient Care (CA)• Medical Knowledge• Practice Based

Learning and Improvement (OS)

• Interpersonal and Communication Skills (IS)

• Professionalism (GD)• Systems-Based

Practice (BP)

• Osteopathic Principles and Practice


Specific CompetenciesSpecific Competencies

• Patient Care– communicate

effectively

– gather essential and accurate information

– make informed decisions

– carry out patient management plans

• Patient Care (cont’d)– counsel and educate– use information

technology– perform procedures

competently– preventing health

problems or maintain health

– work with health care professionals



• Medical Knowledge– investigatory and

analytic thinking

– apply the basic and clinically supportive sciences

• Practice Based Learning and Improvement– perform practice-based

improvement

– evidence

– population



• Practice Based Learning and Improvement (cont’d)

– appraisal of clinical studies

– information technology to manage information

– facilitate the learning of others

• Systems-Based Practice– systems thinking

– medical practice and delivery systems

– cost-effective health care

– quality

– partnership


• Interpersonal and Communication Skills– therapeutic and

ethically sound relationship

– effective listening

– health care team

• Professionalism– respect, compassion,

integrity

– commitment to ethical principles

– sensitivity



• Osteopathic Principles and Practice– the body is a unit; the person is a unit of body, mind,

and spirit

– the body is capable of self-regulation, self-healing, and health maintenance

– structure and function are reciprocally interrelated

– rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function



Changing the Accreditation FocusChanging the Accreditation Focus

COMPLIANCE– Does the program

comply with the requirements?

– Does the program have established objectives and an organized curriculum?

– Does the program evaluate its residents and itself?

DEMONSTRATE– Does the program

achieve its objectives?

– What evidence can it provide that it does so?

– How does the program demonstrate continuous improvement?

From Dianne M. Hartmann, MD, University of Rochester



Competencies

INSTRUCTION

Formative Evaluation

REMEDIATION



Teaching Strategies: TypesTeaching Strategies: Types

• Group-based Instruction– Most acceptable and effective strategy for the

group as a whole (80/20 rule)

• Instructional Correctives/Remediation– Influenced by specific learning styles and needs

(corrects the teacher’s behavior)


...the only people for me are the mad ones, the ones who are mad to live, mad to talk, mad to be saved, desirous of everything at the same time,

the ones who never yawn or say a commonplace thing, but burn, burn, burn like fabulous yellow roman candles exploding like spiders across the

stars and in the middle you see the blue centerlight pop and everybody goes, "Awww!”

- Kerouac


Teaching Strategy ExamplesTeaching Strategy Examples

• Tufts Managing Care Curriculum• Integrating Improvement Competencies into UNC

Pediatric Residency Education• Innovations in Leadership: Professionalism and

Systems (Loyola)• Teaching Practice-Based Learning and

Improvement, Interpersonal and Communication Skills, and Systems Based Practice with a Senior Resident Seminar and Team Project (Mayo)


R.S.V.P.R.S.V.P.

• Recognize Success Via ImPlementation

www.acgme.org/outcome/implement/rsvp.asp


ACCOUNTABILITYACCOUNTABILITY


AccountabilityAccountability

• Definition• Learner’s Domain

– Accountable for choosing a curriculum– Accountable for Learning

• Teacher’s Domain– Accountable for Curriculum Implementation

(RRC)– Accountable for giving effective feedback– Accountable for Clinical Care


Clinical CareClinical Care

• The tasks of clinical care may be delegated– this is a critically important teaching strategy

• The accountability for clinical care may not be delegated– faculty are always accountable for clinical care

While residents may deliver care, faculty remain fully accountable for the care that is delivered



Competencies

Instruction

FORMATIVE EVALUATION

Remediation



Formative EvaluationFormative Evaluation

• Formative Evaluation is the coming together of the following 3 components for the teacher:– Feedback– Redirection based on the competencies of the

curriculum– Facilitate discovery through encouragement


FeedbackFeedback

KnownWorld

HiddenWorld

SecretWorld

UnknownWorld

Feedback

Revelation

Disclosure

KNOWN UNKNOWN

KNOWN

UNKNOWN

YOU

THEM


ACGME ToolboxACGME Toolbox

• 360 Degree• Chart Stimulated

Recall• Checklist• Global Rating• OSCE• Standardized Patient

Exam• Written Exam (MCQ)

• Procedure, Operative or Case Logs

• Patient Surveys• Portfolios• Record Review• Simulations/Models• Standardized Oral

Exam


Direct FlightDirect Flight


Connecting FlightConnecting Flight


Going as far out of your way as is humanly possible

Going as far out of your way as is humanly possible


Some learners...Some learners...

• Take Direct Flights

• Take Connecting Flights

• Go as far out of their way as is humanly possible

Our challenge is to work effectively with all learners regardless of the particulars of

their specific journey


EncouragementEncouragement

• I believe in you

• I trust you

• I know you can handle this

• You are listened to

• You are cared for

• You are very important to me



RELATIONSHIPRELATIONSHIP


Kathleen N. LohrKathleen N. Lohr

“Quality measurement should involve both processes and outcomes of care; a focus on only one

will be a mistake. Today’s focus on outcomes management in the United States will not be the

answer to all of the quality problems likely to arise tomorrow.”


Formative versus Summative Evaluation

Formative versus Summative Evaluation

• Formative evaluation (forming the development of the learner) is central to CBE

• Summative evaluation (summarizing achievement) is not a component of CBE

• Evaluation (assigning a value) is entirely subjective, but is made most reliable and valid through examination of accurate and complete data


Summative Evaluation: In the Learner’s Domain*Summative Evaluation:

In the Learner’s Domain*• Safety emanates from relationship, hence

relationship building is critical• Clearly stated expectations ease the

formation of safe relationships• Non-judgmental respect for a learner’s

process eases the formation of safe relationships

* regarding educational accountability - performed on behalf of growth and development


The Johari Cycle*The Johari Cycle*

Feedback

Revelation and Disclosure

*Bell


Summative EvaluationSummative Evaluation

• When learner’s feel safe, they are more likely to revelate and disclose, hence learn and grow

• Ongoing formative evaluation must occur - both a teacher and a learner responsibility

• Dysfunctional learning must be addressed AND it must be addressed outside of this relationship


Summative Evaluation for Teachers*

Summative Evaluation for Teachers*

• Promotion and advancing responsibility

• Graduation

• Reference Letters

* regarding clinical accountability - performed on behalf of our covenant with society


SAFETYSAFETY


The experience of safety may be the single most important

determinant with respect to a student’s likelihood to learn and

grow


Lucian L. Leape, MDLucian L. Leape, MD

“Non-punitive means people are not punished for making mistakes - nothing more. It doesn’t mean that people are not punished for misconduct - nothing less. People should never be punished for errors - ever. The nonpunitive environment recognizes that no one (other than a psychopath) makes a

mistake on purpose and that human errors result from faulty systems, not from faulty people. The person who makes a mistake, like the injured patient, is the victim of a system

failure. It is the system that must be changed, not the individual.”


Realms of Safety for LearnersRealms of Safety for Learners

• Safe for the learner to ask questions• Safe for the learner to risk their thinking• Safe for the learner to practice new skills• Safe for the learner to challenge established

constructs• Safe for the learner to be seen as vulnerable• Safe learning environment - e.g. work hrs.• Patient safety


SummarySummary

• Clarity is achieved through definition of competency and thorough teaching

• Accountability is attended to by learners and teachers, but in different ways

• Attention to relationship allows for a focus on process as well as outcome

• Safety may be the most important issue to contend with


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