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.
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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.
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Assessing resident performance in these competencies is challenging,5
so in 2009, the ACGME and the American Board of Internal Medicine introduced subcompetencies6
—also called reporting milestones—under the Next Accreditation System (NAS).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.
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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
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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
| Competency | Reporting milestone | Description |
|---|---|---|
| Patient care | PC1 | Gathers and synthesizes essential and accurate information to define a patient's clinical problem |
| PC2 | Develops and achieves comprehensive management plan for each patient | |
| PC3 | Manages patients with progressive responsibility and independence | |
| PC4 | Skill in performing procedures | |
| PC5 | Requests and provides consultative care | |
| Medical knowledge | MK1 | Clinical knowledge |
| MK2 | Knowledge of diagnostic testing and procedures | |
| Systems-based practice | SBP1 | Works effectively within an interprofessional team |
| SBP2 | Recognizes system error and advocates for improvement | |
| SBP3 | Identifies forces that impact the cost of health care and advocates for and practices cost-effective care | |
| SBP4 | Transitions patients effectively within and across health delivery systems | |
| Practice-based learning and improvement | PBLI1 | Monitors practice with a goal for improvement |
| PBLI2 | Learns and improves via performance audit | |
| PBLI3 | Learns and improves via feedback | |
| PBLI4 | Learns and improves at the point of care | |
| Professionalism | PROF1 | Has professional and respectful interactions with patients, caregivers, and members of the professional team |
| PROF2 | Accepts responsibility and follows through on tasks | |
| PROF3 | Responds to each patient's characteristics and needs | |
| PROF4 | Exhibits integrity and ethical behavior in professional conduct | |
| Interpersonal and communication skills | ICS1 | Communicates effectively with patients and caregivers |
| ICS2 | Communicates effectively in interprofessional teams | |
| ICS3 | Appropriate 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.
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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.
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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.9
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
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regarding a patient with an unfortunate outcome that occurred in the setting of several widely recognized cognitive errors.11
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, 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.14
This case also illustrates transformative learning,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.
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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.16
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.17
The Residents' Clinic article by Vatterott et al
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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
- A man with fever, cough, and rash.N Engl J Med. 2015; 373: 74-80
- Enlarged thymus in a patient with dyspnea and weight loss.JAMA. 2015; 313: 2174-2175
- The ACGME Outcome Project: retrospective and prospective.Med Teach. 2007; 29: 648-654
- Barriers to implementing the ACGME Outcome Project: a systematic review of program director surveys.J Grad Med Educ. 2012; 4: 425-433
- Perspective: competencies, outcomes, and controversy—linking professional activities to competencies to improve resident education and practice.Acad Med. 2011; 86: 161-165
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.
- The next GME accreditation system—rationale and benefits.N Engl J Med. 2012; 366: 1051-1056
- Assessment not only drives learning, it may also help learning.Med Educ. 2009; 43: 5-6
- Benchmarks of support in internal medicine residency training programs.Acad Med. 2002; 77: 50-56
- 75-Year-old man with fever, cough, myalgias and pruritis.Mayo Clin Proc. 2015; 90: 1694-1698
- The importance of cognitive errors in diagnosis and strategies to minimize them.Acad Med. 2003; 78: 775-780
- From mindless to mindful practice—cognitive bias and clinical decision making.N Engl J Med. 2013; 368: 2445-2448
- Thinking Fast and Slow.Farrar, Straus and Giroux, New York, NY2011
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.
- Understanding and Promoting Transformative Learning: A Guide for Educators of Adults.2nd ed. Jossey-Bass, San Francisco, CA2006
- Perspective: transformative learning; a framework using critical reflection to link the improvement competencies in graduate medical education.Acad Med. 2010; 85: 1790-1793
- A systems approach to morbidity and mortality conference.Am J Med. 2010; 123: 663-668
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© 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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- 75-Year-Old Man With Fever, Cough, Myalgias, and PruritusMayo Clinic ProceedingsVol. 90Issue 12
- PreviewA 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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