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Residents' Clinic Articles in the Age of Competency-Based Medical Education

      Mayo Clinic Proceedings began publishing Residents' Clinic articles in 1995. The purpose of Residents' Clinics is for internal medicine residents to describe—through narratives, multiple choice questions (MCQs), and explanations of the MCQ answers—the evaluation of patients who are managed by internists with respect to diagnosis, treatment, and prognosis. The traditional focus of Residents' Clinics is to enhance readers' reasoning skills and medical knowledge of diseases that occur in adults. Other journals that publish similar articles on knowledge and clinical reasoning are New England Journal of Medicine and JAMA.
      • Geller B.J.
      • Stone R.M.
      • Merola J.F.
      • Levy B.D.
      • Loscalzo J.
      A man with fever, cough, and rash.
      • Huang W.
      • Molitch M.E.
      Enlarged thymus in a patient with dyspnea and weight loss.
      However, it is noteworthy that physicians' expertise in managing patients extends beyond acquiring and displaying medical knowledge.
      In 2001, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcomes Project, which required that residents demonstrate proficiency in the following six competencies: (1) patient care, (2) medical knowledge, (3) systems-based practice, (4) practice-based learning and improvement, (5) professionalism, and (6) interpersonal and communication skills.
      • Swing S.R.
      The ACGME Outcome Project: retrospective and prospective.
      • Malik M.U.
      • Diaz Voss Varela D.A.
      • Stewart C.M.
      • et al.
      Barriers to implementing the ACGME Outcome Project: a systematic review of program director surveys.
      Assessing resident performance in these competencies is challenging,
      • Jones Jr., M.D.
      • Rosenberg A.A.
      • Gilhooly J.T.
      • Carraccio C.L.
      Perspective: competencies, outcomes, and controversy—linking professional activities to competencies to improve resident education and practice.
      so in 2009, the ACGME and the American Board of Internal Medicine introduced subcompetencies

      Internal Medicine Milestone Group. The Internal Medicine Milestones Project: A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Accreditation Council for Graduate Medical Education website. http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf. Published July 2015. Accessed July 31, 2015.

      —also called reporting milestones—under the Next Accreditation System (NAS).
      • Malik M.U.
      • Diaz Voss Varela D.A.
      • Stewart C.M.
      • et al.
      Barriers to implementing the ACGME Outcome Project: a systematic review of program director surveys.
      • Nasca T.J.
      • Philibert I.
      • Brigham T.
      • Flynn T.C.
      The next GME accreditation system—rationale and benefits.
      Reporting milestones provide the advantages of behavior-specific anchors and an ability to gauge residents' progress over time (Table).
      TableAccreditation Council for Graduate Medical Education Competencies and Reporting Milestones
      Each milestone is rated on a 9-point scale with descriptive anchors, ranging from “critical deficiencies” to “ready for unsupervised practice” to “aspirational.” For more information, see the Accreditation Council for Graduate Medical Education's and American Board of Internal Medicine's Internal Medicine Milestones Project.6
      CompetencyReporting milestoneDescription
      Patient carePC1Gathers and synthesizes essential and accurate information to define a patient's clinical problem
      PC2Develops and achieves comprehensive management plan for each patient
      PC3Manages patients with progressive responsibility and independence
      PC4Skill in performing procedures
      PC5Requests and provides consultative care
      Medical knowledgeMK1Clinical knowledge
      MK2Knowledge of diagnostic testing and procedures
      Systems-based practiceSBP1Works effectively within an interprofessional team
      SBP2Recognizes system error and advocates for improvement
      SBP3Identifies forces that impact the cost of health care and advocates for and practices cost-effective care
      SBP4Transitions patients effectively within and across health delivery systems
      Practice-based learning and improvementPBLI1Monitors practice with a goal for improvement
      PBLI2Learns and improves via performance audit
      PBLI3Learns and improves via feedback
      PBLI4Learns and improves at the point of care
      ProfessionalismPROF1Has professional and respectful interactions with patients, caregivers, and members of the professional team
      PROF2Accepts responsibility and follows through on tasks
      PROF3Responds to each patient's characteristics and needs
      PROF4Exhibits integrity and ethical behavior in professional conduct
      Interpersonal and communication skillsICS1Communicates effectively with patients and caregivers
      ICS2Communicates effectively in interprofessional teams
      ICS3Appropriate utilization and completion of health records
      a Each milestone is rated on a 9-point scale with descriptive anchors, ranging from “critical deficiencies” to “ready for unsupervised practice” to “aspirational.” For more information, see the Accreditation Council for Graduate Medical Education's and American Board of Internal Medicine's Internal Medicine Milestones Project.

      Internal Medicine Milestone Group. The Internal Medicine Milestones Project: A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Accreditation Council for Graduate Medical Education website. http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf. Published July 2015. Accessed July 31, 2015.

      With multiple competencies and subcompetencies, why would there be such emphasis on the competency of medical knowledge in graduate medical education? There are several reasons. First, assessment drives learning.
      • Wood T.
      Assessment not only drives learning, it may also help learning.
      In other words, people are strongly motivated to understand information that is required for high-stakes assessments. The medical knowledge certification examination, which internists must pass every 10 years in order to maintain board certification, is one such motivation for continuous learning. Second, board pass rates are a key metric for determining the quality of residency training programs.
      • Wolfsthal S.D.
      • Beasley B.W.
      • Kopelman R.
      • Stickley W.
      • Gabryel T.
      • Kahn M.J.
      Membership Survey and Scientific Data Committee, the Association of Program Directors of Internal Medicine
      Benchmarks of support in internal medicine residency training programs.
      Third, competencies like professionalism and communication are more challenging to objectively measure than medical knowledge, so they may be understressed. The ACGME and NAS milestones-based assessments require that residents exhibit a wide range of competencies that transcend awareness of diseases to include caring for the whole patient within the contexts of physician-patient relationships, medical teams, and the health care system. Therefore, residents should be encouraged to think broadly about their clinical experiences when writing Residents' Clinic contributions.
      This issue of the Proceedings includes a Residents' Clinic article by Vatterott et al
      • Vatterott P.C.
      • Schouten W.M.
      • Wittich C.M.
      75-Year-old man with fever, cough, myalgias and pruritis.
      regarding a patient with an unfortunate outcome that occurred in the setting of several widely recognized cognitive errors.
      • Croskerry P.
      The importance of cognitive errors in diagnosis and strategies to minimize them.
      • Croskerry P.
      From mindless to mindful practice—cognitive bias and clinical decision making.
      • Kahneman D.
      Thinking Fast and Slow.
      Reflecting on one's mistakes in clinical reasoning is consistent with the ACGME's definition of practice-based learning and improvement, which underscores the importance of improving patient care through constant self-evaluation.

      Accreditation Council for Graduate Medical Education. Outcomes Project. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/430_CompetencyDefinitions_RO_ED_10182007.pdf. Accessed October 19, 2015.

      This case also illustrates transformative learning,
      • Cranton P.
      Understanding and Promoting Transformative Learning: A Guide for Educators of Adults.
      which is growth of awareness through changing one's worldview. Transformative learning requires a disorienting dilemma such as a cognitive error, reflecting on the dilemma to expose areas for improvement, and then addressing limitations by acquiring new knowledge, skills, or attitudes. In fact, transformative learning has been identified as a link between practice-based learning and improvement and large-scale improvements in the health care system.
      • Wittich C.M.
      • Reed D.A.
      • McDonald F.S.
      • Varkey P.
      • Beckman T.J.
      Perspective: transformative learning; a framework using critical reflection to link the improvement competencies in graduate medical education.
      Furthermore, learning from errors reaffirms the culture of transparency in modern training programs and the systems audit approach to discussing medical errors at morbidity and mortality conferences.
      • Szostek J.H.
      • Wieland M.L.
      • Loertscher L.L.
      • et al.
      A systems approach to morbidity and mortality conference.
      The Residents' Clinic article by Vatterott et al
      • Vatterott P.C.
      • Schouten W.M.
      • Wittich C.M.
      75-Year-old man with fever, cough, myalgias and pruritis.
      marks a substantial departure from previous Residents' Clinics over the past 20 years, which have included MCQs that address only the medical knowledge and patient care competencies. This new approach reveals the complex abilities required of internists, which would also include systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. Ultimately, the article by Vatterott et al should align Residents' Clinics with the milestones-based objectives of the ACGME and NAS in this era of competency-based education.
      Looking forward, we anticipate that most Residents' Clinic articles will continue to focus mainly on patient cases that represent the medical knowledge and patient care competencies. Nonetheless, we will broaden the scope of Residents' Clinics by considering manuscripts that demonstrate, in a compelling fashion, any of the ACGME competencies. Examples could include clinical scenarios that show methods for effective physician-patient communication, improving health care systems, or resolving ethical dilemmas.

      References

        • Geller B.J.
        • Stone R.M.
        • Merola J.F.
        • Levy B.D.
        • Loscalzo J.
        A man with fever, cough, and rash.
        N Engl J Med. 2015; 373: 74-80
        • Huang W.
        • Molitch M.E.
        Enlarged thymus in a patient with dyspnea and weight loss.
        JAMA. 2015; 313: 2174-2175
        • Swing S.R.
        The ACGME Outcome Project: retrospective and prospective.
        Med Teach. 2007; 29: 648-654
        • Malik M.U.
        • Diaz Voss Varela D.A.
        • Stewart C.M.
        • et al.
        Barriers to implementing the ACGME Outcome Project: a systematic review of program director surveys.
        J Grad Med Educ. 2012; 4: 425-433
        • Jones Jr., M.D.
        • Rosenberg A.A.
        • Gilhooly J.T.
        • Carraccio C.L.
        Perspective: competencies, outcomes, and controversy—linking professional activities to competencies to improve resident education and practice.
        Acad Med. 2011; 86: 161-165
      1. Internal Medicine Milestone Group. The Internal Medicine Milestones Project: A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Accreditation Council for Graduate Medical Education website. http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf. Published July 2015. Accessed July 31, 2015.

        • Nasca T.J.
        • Philibert I.
        • Brigham T.
        • Flynn T.C.
        The next GME accreditation system—rationale and benefits.
        N Engl J Med. 2012; 366: 1051-1056
        • Wood T.
        Assessment not only drives learning, it may also help learning.
        Med Educ. 2009; 43: 5-6
        • Wolfsthal S.D.
        • Beasley B.W.
        • Kopelman R.
        • Stickley W.
        • Gabryel T.
        • Kahn M.J.
        • Membership Survey and Scientific Data Committee, the Association of Program Directors of Internal Medicine
        Benchmarks of support in internal medicine residency training programs.
        Acad Med. 2002; 77: 50-56
        • Vatterott P.C.
        • Schouten W.M.
        • Wittich C.M.
        75-Year-old man with fever, cough, myalgias and pruritis.
        Mayo Clin Proc. 2015; 90: 1694-1698
        • Croskerry P.
        The importance of cognitive errors in diagnosis and strategies to minimize them.
        Acad Med. 2003; 78: 775-780
        • Croskerry P.
        From mindless to mindful practice—cognitive bias and clinical decision making.
        N Engl J Med. 2013; 368: 2445-2448
        • Kahneman D.
        Thinking Fast and Slow.
        Farrar, Straus and Giroux, New York, NY2011
      2. Accreditation Council for Graduate Medical Education. Outcomes Project. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/430_CompetencyDefinitions_RO_ED_10182007.pdf. Accessed October 19, 2015.

        • Cranton P.
        Understanding and Promoting Transformative Learning: A Guide for Educators of Adults.
        2nd ed. Jossey-Bass, San Francisco, CA2006
        • Wittich C.M.
        • Reed D.A.
        • McDonald F.S.
        • Varkey P.
        • Beckman T.J.
        Perspective: transformative learning; a framework using critical reflection to link the improvement competencies in graduate medical education.
        Acad Med. 2010; 85: 1790-1793
        • Szostek J.H.
        • Wieland M.L.
        • Loertscher L.L.
        • et al.
        A systems approach to morbidity and mortality conference.
        Am J Med. 2010; 123: 663-668

      Linked Article

      • 75-Year-Old Man With Fever, Cough, Myalgias, and Pruritus
        Mayo Clinic ProceedingsVol. 90Issue 12
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          A 75-year-old man presented to the emergency department (ED) with a 5-day history of fever, cough, nasal congestion, sore throat, myalgias, headache, loose stools, and diffuse pruritus. His medical history was notable for coronary artery bypass graft surgery several years previously, hypertension, hyperlipidemia, chronic kidney disease, acid reflux, alcohol abuse, and gout. He had taken acetaminophen with modest improvement in his fever, myalgias, and headache. He was a lifelong nonsmoker. The patient had no sick contacts or recent travel history.
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