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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_112_библиотеки_им_акад_М_И_Перельмана
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b. Openness and legal or disciplinary
proceedings
c. Honesty in financial dealings
ACGME/ABMS General Competencies (United States)
Competency
Domain
Subcompetencies
Patient Care Residents must be able to perform all
medical, diagnostic, and surgical
procedures considered essential for the
area of practice.Subcompetencies vary by
specialty and often target specific
conditions (e.g., chronic illness) or settings
(e.g., ambulatory clinic), and includes:
1. Medical interviewing
2. Physical examination
3. Procedural care
Medical
Knowledge
Residents and fellows must demonstrate
knowledge of established and evolving
biomedical, clinical, epidemiological, and
social-behavioral sciences, as well as the
application of this knowledge to patient
care. Subcompetencies vary by specialty,
may target specific conditions (e.g., chronic
illness) or specific domains of knowledge
(e.g., pathophysiology, etc.), and include:
1. Clinical reasoning in the clinical care space
Systems-based
Practice
1. Patient safety and quality improvement
2. System navigation for patient-centered care
3. Physician role in healthcare system
Practice-based
Learning and
Improvement
1. Evidence-based and informed practice
2. Reflective practice and commitment to personal
growth
Professionalism
1. Professional behavior and ethical principles
2. Accountability/conscientiousness
3. Self-awareness and help-seeking
Interpersonal
1. Patient and family-centered communication
2. Interprofessional and team communication
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Communication
Skills
3. Communication with healthcare systems
Institute of Medicine (now National Academy of Medicine;
United States)
1. Employ
evidence-based
practice.
2. Work in
interdisciplinary
teams.
3. Provide patientcentered care.
4. Apply quality
improvement.
5. Utilize
informatics.
ABMS, American Board of Medical Specialists; ACGME, Accreditation Council for
Graduate Medical Education; CanMEDS, Canadian Medical Education Directions
for Specialists.
These competencies are intended as the first step in
identifying the key educational outcomes of individual
healthcare professionals that should inform learning
objectives, assessment, and curriculum of graduate training
programs, adapted to the content, education, and practice of
the particular specialty/subspecialty. As we will see in the
section, Dimension 3: Assessment of Progression, Milestones
and EPAs are constructs and concepts, specified and adapted
by specialties that can facilitate the implementation of
competency-based training. The data produced by the
assessment of competencies serve as a basis for judging the
quality of the trainees and their training, as well as
supporting the continuous improvement of both.
Dimension 2: Levels and Types of
Assessment
The multifaceted nature of the competencies makes it
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apparent that no single method could provide a sufficient
basis for making judgments about learners in health
professions education. In an organized approach to this
problem, George Miller proposed a classification scheme in
1990 that stratifies assessment methods based on what they
require of the trainee and has stood the test of time. Often
referred to as Miller’s pyramid (Fig. 1.4), it is composed of
four levels: knows, knows how, shows how, and does.
92
FIG. 1.4 Miller’s pyramid.
Miller’s Pyramid
Knows. This is the lowest level of the pyramid and it
contains methods that assess what a trainee “knows” in an
area of competence. Forming the base of the pyramid,
knowledge represents the foundation upon which clinical
competence is built. Most MCQ examinations focus on
biologic and clinical domains. However, an MCQ-based
examination composed of questions focused on ethics and
principles of patient confidentiality would provide an
assessment of what a trainee “knows” about key tenets of
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professionalism.
Knows how. To function as a physician, a good knowledge
base is necessary but insufficient. It is important to know
how to apply this knowledge in the acquisition of data, the
analysis and interpretation of findings, and the development
of management plans. Oral examinations, still in use by some
certification boards, are one example of a high-stakes “knows
how” assessment. In the United States, the surgical
certification boards use oral examinations to assess how
recent residency and fellowship graduates would approach a
clinical condition (e.g., trauma). As another example, a
training program used for professionalism might pose a
moral dilemma, asks trainees to reason through it, and
evaluate the sophistication of their moral thinking.
Shows how. Although trainees may know and know how,
they may not be able to integrate these skills into a successful
performance with patients. Consequently, certain assessment
methods require the trainee to show how they perform with
patients. For example, standardized patients may be used to
assess clinical skills such as informed decision-making and
breaking bad news. As another example, a standardized
patient presenting with an ethical challenge would offer the
trainee an opportunity to “show how” they would respond to
a professionalism challenge. Miller referenced this level as
“performance,” akin to an actor on a stage performing under
controlled conditions.
Does. No matter how good traditional assessment methods
become, there remains the concern that what happens in a
controlled testing environment does not generalize directly
or predict what happens in practice. This is evident in studies
of high-stakes MCQ examinations that find, at best, only a
modest correlation of test scores and quality of care provided
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to actual patients.93 The highest level of Miller’s pyramid
therefore focuses on methods that provide an assessment of
routine performance, or what Miller called action. For
example, the development and use of multisource feedback
tools, patient experience surveys, and critical incident
systems, such as the one currently used in some residencies
and medical schools, offers an assessment of what learners
actually do in terms of interpersonal skills and
professionalism.
Miller’s pyramid is a useful framework for considering
differences and similarities among assessment methods.
However, the fact that it is a pyramid might imply to some
that methods addressing the higher levels are better, or
conversely, that the larger area occupied by the base of the
pyramid implies that knowledge assessment is most
important. Instead, superior methods are those best aligned
with the purpose of the assessment. For example, if an
assessment of foundational medical knowledge is needed, a
method associated with that level (e.g., MCQs) is likely better
than a method associated with another level (e.g.,
standardized patients).
Two groups have advocated for changes to Miller’s
pyramid. Cruess and colleagues argued to add “Is” to the top
of the pyramid to recognize the importance of professional
identity formation, but it is not yet clear where this fits into
an assessment program.94 More recently, ten Cate and
colleagues extended the pyramid, placing “Entrusted with
future care” at the top as the ultimate assessment decision.
The Cambridge Model
As physicians near the end of training and enter practice,
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external forces and context come to play a very large role in
performance. The Cambridge Model, a variation on Miller’s
pyramid, proposes that performance in practice (the highest
level of the pyramid) is influenced by two large forces
beyond competence.95 Systems-related factors, such as
government programs, clinical microsystems (i.e., the clinical
units where learners care for patients), institutional care
delivery practices, patient expectations, and guidelines,
among other factors, strongly influence what physicians do.
Similarly, factors related to the individual physician such as
state of mind, physical and mental health, and relationships
with peers and family have a significant effect. Consequently,
assessment becomes more difficult because it is harder to
disentangle the effects of the context (e.g., context specificity;
see Chapter 8) of care from the competence of the individual
physician. Here, a focus on healthcare processes and
outcomes as a measure of what a physician “does” can
provide a robust assessment of a physician’s ability to
integrate multiple competencies within a complex social
context.
However, processes and outcomes are still impacted by
system factors that can affect patient preferences and thus
impact the measurement of processes of care such as the
availability of specific services that may also impact
outcomes. Fig. 1.5 highlights the complex, interdependent
interactions and relationships involved in caring for patients.
Assessment programs must consider the impact of these
relationships when designing and implementing assessment
programs because of the significant intersection and
dependence of educational outcomes and quality of care
provided to patients.
54,96,97
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FIG. 1.5 Changing perspective: patients at the intersection of
educational and healthcare outcomes.
Dimension 3: Assessment of
Progression
Acquiring competence is not an overnight process. Trainees
progress through a series of stages that begin in
undergraduate medical education and continue throughout
their careers. Educators must be able to recognize when a
trainee has attained sufficient knowledge, skills, and
attitudes to enter the next stage and this requires appropriate
standards and benchmarks for the transition. Hurbert
Dreyfus and Stuart Dreyfus created a developmental model
of learning applicable to the health professions that proposes
five stages of educational development (Table 1.4).
24,97
Table 1.4
The Stages of Learning as Proposed by Dreyfus
Stage of
Learning
Method of
Learning
(Teaching Style)
Learning
Steps
Learner
Characteristics
1. Novice
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Instruction
(instructor)
Breaks skill
into contextfree, discrete
tasks, concepts,
rules
Recognizes
the contextfree features
Knows rules
for
determining
actions
based on
these
features
Learning
occurs in a
detached
analytic frame
of mind
2.
Advanced
beginner
Practice (coach)
Experiences
coping with
real situations
Points out new
aspects of
material
Teaches rules
and reasoning
techniques for
action
Recognizes
relevant
aspects based
on experience
that makes
sense of the
material
Learns
maxims
about
actions
based on
new material
Learning
occurs in a
detached,
analytic frame
of mind
3.
Competence
Apprenticeship
(facilitator)
Develops a
plan or
chooses
perspective
that separates
“important”
from
“ignored”
elements
Demonstrates
that rules and
reasoning
techniques for
choosing are
Volume of
aspects is
overwhelming
Performance
is exhausting
Sense of
what’s
important is
lacking
Stands alone
in making
correct and
incorrect
choices
Coping
becomes
Learner is
emotionally
involved in
the task and
its outcome
Too many
subtle
differences
for rules;
student must
decide in
each case
Makes a
mistake,
then feels
remorse
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difficult to
come by
Role models
also
emotionally
involved in
making
decisions
frightening,
discouraging,
elating
Succeeds,
then feels
elated
Emotional
learning
builds
competence
4.
Proficiency
Apprenticeship
(supervisor)
Gains more
specific
experience
with outcomes
of one’s
decisions
Applies rules
and maxims to
decide what to
do
Rules and
principles are
replaced by
situational
discrimination
Emotional
responses to
success or
failure build
intuitive
responses
that replace
reasoned
ones
Learner
immediately
sees the goal
and salient
features
Learner
reasons how
to get to the
goal by
applying
rules and
principles
5.
Expertise
Independence
(mentor)
Experiences
multiple, small
random
variations
Observes other
experts or
experiences
nonrandom
simulations
Working
through the
cases must
emotionally
matter
Gains
experience
with
increasingly
subtle
variations in
situations
Automatically
distinguishes
situations
requiring
one response
from those
requiring
another
Immediately
sees the goal
and what
must be done
to achieve it
Builds on
previous
learning
experiences
From Dreyfus HL. On the Internet. Thinking in Action Series. Routledge; 2001.
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The characteristics of learners and the steps they must go
through to acquire competence will change over the five
stages of development, and each step, or stage, does not
occur in a linear fashion (Fig. 1.6). Necessarily, the methods
of assessment applied at each developmental level will likely
also evolve. For example, at the level of the novice, an MCQbased knowledge test might be most appropriate, but a
standardized patient–based examination might be better
suited to learners who are in the competence or proficiency
stage depending on the competency of interest. It is
important to realize that learners are typically at different
stages for different competencies, depending on the content
and context of the task and competency being assessed. This
observation has been clearly seen in the US Milestones data
and other studies of learning curves.98 For example, a
resident may be seen as “proficient” in working up a patient
with chest pain, but at the “advanced beginner” level in
counseling a patient regarding end-of-life care. Likewise,
many students achieve competence with regard to medical
knowledge, or perhaps communication skills, before they
acquire the same level in more challenging systems-based
practice domains such as care coordination or cost-conscious
care delivery.
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