Dean's Newsletter

Archive of previous newsletters

Fostering excellence in education and clinical practice

March 16, 2006

How would you define an excellent physician? Certainly, he or she should have comprehensive medical knowledge about his or her field of expertise, and superb technical skills in providing patient care. These attributes have, indeed, been the traditional hallmarks of residency training.

But think about it. If you were to recall the care of a physician whom you would describe as "excellent," I'll bet you would be thinking about other qualities as well. In addition to excellent medical knowledge and skill, qualities that we all look for in a physician include excellence in communication (with patients, family members, peers, and staff), exemplary professionalism in terms of integrity and ethics, the ability to learn and grow from his or her own practice in a manner that fosters continual quality improvement, and effectiveness as a member of a health care team.

In this newsletter, I will present an idea related to achieving this level of comprehensive physician excellence across the entire continuum of medical education at the medical school—from medical students to residents to practicing physicians. This idea, which could possibly be extended to include nursing and dental education, represents an extension of principles around "core competencies" that are being worked out on a national level, and in the work of our Associate Dean for Graduate Medical Education, Diane Hartmann, MD.

By way of background, in 1999 the Accreditation Council for Graduate Medical Education (ACGME—the agency responsible for accrediting all US medical residency and fellowship programs) initiated a program designed to specify, measure and evaluate six core competencies among trainees in U.S. GME programs. These core competencies are: patient care, medical knowledge, communication, professionalism, practice-based learning and improvement, and systems-based practice.

At the time, I was Chair of Ob/Gyn and Diane was our Residency Program Director. After attending a national meeting on the new ACGME guidelines, Diane returned to Rochester and reported, at a regularly scheduled meeting regarding the Ob/Gyn residency program, that we would now have to document the ways in which our residency program was providing education in each of the core competencies, and measure our residents' success in achieving these competencies. Many around the table were thinking the same thing—"Here they go again; the medical education establishment has conjured up a plan that creates more work for us to justify their existence. Why can't they just let us train the residents today the same way that we were trained?"

Well, time passed and the ideas about core competencies gradually took hold. We were wrong to think in such a narrow-minded fashion. The "competent graduate" of our GME programs is indeed a physician who possesses more than traditional medical knowledge and technical skills. He or she will critically analyze the medical literature, comfortably practice evidence-based medicine at the highest ethical standard without conflict, effectively communicate in a multicultural society, continuously assess the quality of care provided, and participate as an effective team member in today's complex health care delivery systems.

Diane Hartmann, MD, Associate Dean for Graduate Medical Education

Incorporating learning opportunities in each of these competency domains has indeed been an important goal for our GME training programs over the past few years. Program directors have worked with medical faculty and other professional colleagues to teach and assess competence in each of these areas by our trainees. We know that medical knowledge is easily evaluated using written tests, but several programs have assessed their trainees' knowledge at a deeper level by using structured oral examinations as well. Patient care skills including surgical technique are being directly observed and assessed in "real time" with feedback given to the resident immediately after completion of the patient encounter. Nurses, social workers and other professionals who work side by side with our trainees are being asked to complete peer evaluations regarding a resident's communication skills and professionalism. Residents are being challenged to examine the quality of care they provide by comparing their patients' outcomes to national guidelines and standards. Several programs have assigned trainees to take part in quality improvement initiatives within their departments. System-based practice skills, such as the performance of a root cause analysis, are being documented by residents as entries in their learning portfolios.

The idea of focusing on core competencies in medical education has now been extended beyond GME. Cognizant of its role as a stakeholder in graduate medical education, and recognizing that medical education should be viewed as a continuum rather than an isolated event, the American Board of Medical Specialties has recently endorsed the practice of evaluating the six general competencies during initial board certification and reassessing them at regular intervals. Practicing physicians will be required to demonstrate continued competence in these areas to maintain board certification.

OK. Let's now go back to the idea of achieving a high level of comprehensive physician excellence across the entire continuum of medical education. If GME trainees and specialist faculty are being asked to acquire competence in the six domains, couldn't this idea be taken back to medical students and extended to include nurses and dentists? In a very real sense, as Diane put it, shouldn't the institutions in which health care education and practice take place be competent, overall, in these domains?

Imagine the intellectual power that could be generated if we were all to focus on important aspects of written, spoken and digital communication across the health system. Think of the impact of always being mindful of potential systems improvements when we engage in the care of individual patients. And how much easier would it be to teach the elements of professionalism to our medical students knowing that our own departmental environments have been assessed and improved regarding professional interactions and ethical decision making?

A "Competent Institution" is a professional home where individuals can learn and maintain their competence in all aspects of their profession, as well as a place where performance excellence permeates all levels of the organization. To know that our collective efforts have made a difference, i.e., to function as a fully competent institution, educational and clinical outcomes will need to be identified and measured to demonstrate the attainment of individual competence as well as departmental and institutional success.

Other medical centers have focused efforts within one domain, such as patient safety, but none has committed as an institution to the entire spectrum of core competencies. In embracing this challenge, the University of Rochester is poised to once again distinguish itself nationally in innovative medical education and quality patient care.

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry