Special section: Competency—when, why,how?

Addressing the ‘‘general competencies’’:What is this all about?Jeffrey L. Ponsky, MD, FACS, Cleveland, Ohio

From the Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio

S U R G E R YJANUARY 2004

Volume 135 Number 1

IN JUST A SHORT TIME IT SEEMS AS THOUGH the world ofgraduate medical education has been turnedupside down with new regulations, unfamiliarlanguage, and intimidating deadlines. After almosta century of training residents in a fairly standard-ized fashion involving long hours of patient care,careful study, and predominantly subjective evalu-ation, those responsible for supervising this educa-tion are being asked to restructure both the designof their educational programs and the means bywhich the outcome of this training is evaluated.Almost simultaneously the Accreditation Councilfor Graduate Medical Education has informedresidency program directors that they must assurethat work hours are limited to 80 hours per weekand that they must begin to implement a pro-gram in teaching and assessing the ‘‘GeneralCompetencies.’’1 Although the issues regardingresident work hours have tremendous implications,

Accepted for publication April 6, 2003.

Reprint requests: Jeffrey L. Ponsky, MD, Department of Surgery,The Cleveland Clinic Foundation, 9500 Euclid Avenue, DeskA-80, Cleveland, OH 44195.

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particularly in the surgical specialties, residencyprogram directors understand these requirementsand may address them without misunderstand-ing. However, the concepts and language of the‘‘general competencies’’ and the methods by whichto modify existing training schemes to provideexperience in and assessment of these areas aresomewhat foreign to most program directors.2

Although some have embraced the concepts andbegun their implementation,3 others have ques-tioned whether these assessments will ultimatelyimprove the quality of resident training.4 It is im-portant to note at the outset that these conceptsand requirements were enunciated by a team ofexperienced medical educators with the goal of im-proving and standardizing the product of graduatemedical education.

The ‘‘General Competencies’’ include 6 areas inwhich experience must be provided and assessmentaccomplished. These include:

1. Patient care—The residency program must en-sure that its residents, by the time they graduate,provide appropriate, effective, and compassion-ate clinical care. Residents are expected to:a. Communicate effectively and demonstrate

caring and respectful behaviors when inter-acting with patients and patients’ families.

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b. Gather essential and accurate informationabout the patient and use it together with up-to-date scientific evidence to make decisionsabout diagnostic and therapeutic interven-tions.

c. Develop and carry out patient managementplans.

d. Provide education and counseling to patients.e. Perform competently all medical and invasive

procedures essential for the area of practice.f. Provide health care services aimed at pre-

venting health problems or maintaininghealth.

g. Work with other health care professionals toprovide patient focused care.

2. Medical knowledge—The residency program mustensure that its residents, by the time they grad-uate, possess knowledge in established and evolv-ing biomedical and clinical science domains andapply it to clinical care. Residents are expected to:a. Demonstrate rigor in their thinking about

clinical situations.b. Know and apply the basic and clinically

supportive sciences that are appropriate totheir discipline.

3. Practice-based learning and improvement—The resi-dency program must ensure that its residents, bythe time they graduate, are able to investigate,evaluate, and improve their patient care pract-ices. Residents are expected to:a. Analyze practice experience and perform

practice-based improvement activities usingsystematic methodology.

b. Locate, appraise, and assimilate ‘‘best practi-ces’’ related to their patients’ health problems.

c. Apply knowledge of study designs andstatistical methods to the appraisal of clinicalstudies and other information on diagnosticand therapeutic effectiveness.

d. Use information technology to manage in-formation, access on-line medical informa-tion, and support clinical care, patienteducation, and their own education.

4. Interpersonal and communication skills—The resi-dency program must ensure that its residents, bythe time they graduate, can develop appropriateinterpersonal relationships and communicate ef-fectively with patients, patients’ families, and pro-fessional associates. Residents are expected to:a. Create and sustain a therapeutic and ethically

sound relationship with patients.b. Elicit and provide information using effective

nonverbal, explanatory, questioning, andwriting skills.

c. Work effectively with others as a member orleader of a professional group, in particulara health care team that might include pro-fessionals from other disciplines.

5. Professionalism—The residency program mustensure that its residents, by the time they grad-uate, demonstrate the fundamental qualities ofprofessionalism. Residents are expected to:a. Demonstrate respect, regard, integrity, and

a responsiveness to the needs of patients andsociety that supercedes self-interest, assumeresponsibility and act responsibly, and dem-onstrate a commitment to excellence andongoing professional development.

b. Demonstrate a commitment to ethical prin-ciples pertaining to the provision or with-holding of clinical care, confidentiality ofpatient information, informed consent andbusiness practices. Demonstrate sensitivityand responsiveness to cultural differences,including awareness of their own and pa-tients’ cultural perspectives.

6. Systems-based practice—The residency must assurethat its residents, by the time they graduate, areaware that health care is provided in the contextof a larger system and can effectively call on thesystem resources to support the care of patients.Residents are expected to:a. Understand how their patient care practices

and related actions impact component unitsof the health care delivery system and thetotal delivery system, and how deliverysystems impact the provision of health care.

b. Know system-based approaches for control-ling health care costs and allocating resour-ces, and practice cost-effective health careand resource allocation that does not com-promise quality of care.

c. Advocate for quality patient care and assistpatients in dealing with system complexities.

d. Know how to partner with healthcare manag-ers and healthcare providers to assess, coordi-nate, and improve health care and know howthese activities impact system performance.

Although the language is new and the organiza-tion foreign and intimidating, a more carefulreview of these topics will reveal that most programsare presently providing most if not all of therequirements. While we actively pursue and assessthe attainment of medical knowledge and practicethe skills of patient care, the acquisition of skillsin communication, professionalism, systems-basedpractice, and practice-based learning occurs almostwithout notice and certainly without formal assess-

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ment. It is the goal of the Accreditation Council forGraduate Medical Education to assure that all ofthese areas are adequately and purposefullyaddressed and assessed. What we will need todevelop is better means to assure that the materialis properly presented and more adequate tools forassessment of competency in these areas. Suchtools will undoubtedly involve innovative teachingand assessment devices such as simulators, as well asmore traditional evaluation tools such as patientand nursing questionnaires.

We intend to present in this issue a series ofarticles in Surgery that provide more in-depth look

at this material in order to facilitate the under-standing and implementation of the ‘‘GeneralCompetencies’’ by surgical educators.

REFERENCES

1. Leach DC. Evaluation of competency: an ACGME perspec-tive. Am J Phys Med Rehabil 2000;79:487-9.

2. Epstein RM, Hundert EM. Defining and assessing pro-fessional competence. JAMA 2002;287:226-35.

3. Itani K. A positive approach to core competencies andbenchmarks for graduate medical education. Am J Surg2002;184:196-203.

4. Kerfoot BP, Mitchell ME, Novick AC. Grappling with theevaluation of clinical competencies: a view from the resi-dency review committee for urology. Urology 2002;60:223-4.