ACP: Challenges for a competency-based framework for residency training

A guest column by the American College of Physicians, exclusive to

by Steven Weinberger, MD, FACP

Since the Accreditation Council for Graduate Medical Education (ACGME) instituted its Outcome Project approximately 10 years ago, residency training programs have progressively focused on how well their residents have acquired knowledge, skills and attitudes in six broad domains. These “general competencies” include medical knowledge, patient care, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement.

There is general agreement that an expectation for resident competency in each of these areas is appropriate. However, implementing a competency-based framework for training poses several challenges, which I would group into three distinct areas: 1) the inclusion of domains that educational programs have not traditionally addressed; 2) ensuring the reliability and validity of the evaluation process; and 3) determining whether and how acquisition of resident competencies should drive the duration of training.

First, among the six general competencies, systems-based practice and practice-based learning and improvement are unfamiliar areas to most faculty, who must understand the components of these competencies as well as how to teach and evaluate residents in these relatively new areas.

Second, faculty and programs have been challenged to assure that their systems for evaluating residents will provide both reliable and valid assessments. Direct observation of residents in their care of patients is critical, as is evaluation from multiple sources, including patients and nurses as well as physician faculty. But pressures on faculty for clinical and research productivity and progressively shorter teaching assignments have made it more difficult to assure that evaluations can be trusted to reflect residents’ level of competency.

Fortunately, faculty development programs now often focus on evaluation skills, and new tools are being developed as part of the “toolkit” for resident evaluation. However, the time pressures that compromise direct observation of residents by faculty can only be addressed by recognizing the importance of faculty observation and assuring that such time for observation is available.

Finally, in the traditional model for training, the duration of training is fixed, e.g., 36 months for internal medicine residency training. In the competency-based model of training, the duration of training is theoretically not fixed, but dependent upon the time that the resident is deemed competent in the requisite six domains.

There is general agreement that a resident must meet the standards in each of the six general competencies before being allowed to graduate from a residency training program. If a resident has not met these standards, then a plan of remediation or prolongation of training is necessary to assure the resident’s acquisition of all six competencies before graduation. Although it may be logistically difficult to prolong training for a particular resident, it is difficult to argue with the concept that the resident must meet certain standards before being deemed capable of independent practice in the specialty.

On the other hand, there is not general agreement about whether the time independence of competency-based training should afford residents the opportunity to graduate early from training, should they be deemed competent in all six competency domains. Those favoring an opportunity to shorten training argue that training is too long for residents entering subspecialties, and that trainees are relatively old when they finish training, particularly if they are entering a subspecialty.

Those against shortening of training contend that acquisition of sufficient patient experience and professional maturity requires a certain amount of “dwell time,” independent of meeting competency requirements. Other concerns presented by Bordley and co-authors (Am J Med. 2010; 123:188) include forcing of premature career decisions, inadequacy of our current evaluation system, and the logistical issues posed by unpredictability of staffing on teaching services. In addition, early graduation forces disruption of the “learning communities” that are such an important part of residency education, and early graduation of the best residents detracts from the team’s educational environment.

Although I endorse many of the principles of competency-based education, I do feel that the problems with potentially shortening training outweigh the advantages. Until these issues are appropriately addressed, I cast my vote with Bordley et al. in favor of maintaining the current 36 months of training in internal medicine.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.