Accreditation Council For Graduate Medical Education Competencies Research Articles

Vulnerable yet Unprotected: The Hidden Curriculum of the Care of the Incarcerated Patient.

Vulnerable yet Unprotected: The Hidden Curriculum of the Care of the Incarcerated Patient.

Expert Consensus on the Accreditation Council for Graduate Medical Education Competencies That Align With Vascular Quality Initiative Surgical Outcomes

The policy and practice of vascular surgical education has evolved significantly since the advent of the Accreditation Council for Graduate Medical Education (ACGME) Milestones. Concomitantly, greater emphasis has been placed nationally on vascular surgery (VS) quality and outcomes as measured by the Vascular Quality Initiative (VQI) procedure registries. As such, no data have supported the association between the VS ACGME Milestones performance with patient outcomes. To investigate the associations between training and surgical outcomes, a critical first step is to determine which ACGME competencies will contribute to patient outcomes.

Training fellows in neonatal tele-resuscitation using a simulation-based mastery learning model

BackgroundNeonatal tele-resuscitation uses real-time, audio–video telemedicine to connect neonatologists with community hospital care teams during advanced neonatal resuscitations. While telemedicine continues to expand, best practices for training fellows in tele-resuscitation are not known. ObjectiveWe aimed to develop a neonatal tele-resuscitation curriculum using a simulation-based mastery learning model that provides neonatal-perinatal medicine (NPM) fellows with the knowledge, skills, and behaviors needed to lead tele-resuscitations. MethodsUsing technology-enhanced simulation education and a mastery learning model, we developed a longitudinal pilot tele-resuscitation curriculum. From 07/2018 to 03/2021, NPM fellows participated in the curriculum, which included individualized telemedicine learning, observing and leading simulated tele-resuscitations, and finally, performing clinical (non-simulated) tele-resuscitations. A performance assessment tool was developed to assess competency through eight questions mapped to the Accreditation Council for Graduate Medical Education (ACGME) core competencies, with responses on a 1 to 5 scale (1 = critical deficiencies; 5 = competence of an expert). ResultsFour NPM fellows participated in the curriculum, progressing through the curriculum at an individualized pace. Median scores on the three learning modules were 96–100%. Fellows participated in variable number of simulated tele-resuscitations based on when mastery was achieved (2–3 supervised simulations per fellow, 1–4 unsupervised simulations per fellow). In total, eighteen simulated tele-resuscitations (eight unsupervised, 10 supervised) and one clinical tele-resuscitation were conducted. Twenty-five performance assessments were completed. Assessment scores across the ACGME competencies were consistently high, with mean scores ranging from 4.2-4.6, with 4 equating to ‘ready for unsupervised practice’ and 5 equating to ‘competence of an expert’. ConclusionsAs telemedicine use continues to expand, curricula that improve learners’ comfort with and proficiency in tele-resuscitation are essential. A simulation-based mastery learning model may be one approach that affords learners gradual exposure to and mastery of complex tele-resuscitation skills and behaviors.

Gendered Expectations: the Impact of Gender, Evaluation Language, and Clinical Setting on Resident Trainee Assessment of Faculty Performance.

Gender inequity is pervasive in academic medicine. Factors contributing to these gender disparities must be examined. A significant body of literature indicates men and women are assessed differently in teaching evaluations. However, limited data exist on how faculty gender affects resident evaluation of faculty performance based on the skill being assessed or the clinical practice settings in which the trainee-faculty interaction occurs. Evaluate for gender-based differences in the assessment of general internal medicine (GIM) faculty physicians by trainees in inpatient and outpatient settings. Retrospective cohort study SUBJECTS: Inpatient and outpatient GIM faculty physicians in an Internal Medicine residency training program from July 1, 2015, to December 31, 2018. Faculty scores on trainee teaching evaluations including overall teaching ability and Accreditation Council for Graduate Medical Education (ACGME) competencies (medical knowledge [MK], patient care [PC], professionalism [PROF], interpersonal and communication skills [ICS], practice-based learning and improvement [PBLI], and systems-based practice [SBP]) based on the institutional faculty assessment form. In total, 3581 evaluations by 445 trainees (55.1% men, 44.9% women) assessing 161 GIM faculty physicians (50.3% men, 49.7% women) were included. Male faculty were rated higher in overall teaching ability (male=4.69 vs. female=4.63, p=0.003) and in four of the six ACGME competencies (MK, PROF, PBLI, and SBP) based on our institutional evaluation form. In the inpatient setting, male faculty were rated more favorably for overall teaching (male = 4.70, female = 4.53, p=<0.001) and across all ACGME competencies. The only observed gender difference in the outpatient setting favored female faculty in PC (male = 4.65, female = 4.71, p=0.01). Male and female GIM faculty performance was assessed differently by trainees. Gender-based differences were impacted by the setting of evaluation, with the greatest difference by gender noted in the inpatient setting.

Objective predictors of intern performance

BackgroundResidency programs select medical students for interviews and employment using metrics such as the United States Medical Licensing Examination (USMLE) scores, grade-point average (GPA), and class rank/quartile. It is unclear whether these metrics predict performance as an intern. This study tested the hypothesis that performance on these metrics would predict intern performance.MethodsThis single institution, retrospective cohort analysis included 244 graduates from four classes (2015–2018) who completed an Accreditation Council for Graduate Medical Education (ACGME) certified internship and were evaluated by program directors (PDs) at the end of the year. PDs provided a global assessment rating and ratings addressing ACGME competencies (response rate = 47%) with five response options: excellent = 5, very good = 4, acceptable = 3, marginal = 2, unacceptable = 1. PDs also classified interns as outstanding = 4, above average = 3, average = 2, and below average = 1 relative to other interns from the same residency program. Mean USMLE scores (Step 1 and Step 2CK), third-year GPA, class rank, and core competency ratings were compared using Welch’s ANOVA and follow-up pairwise t-tests.ResultsBetter performance on PD evaluations at the end of intern year was associated with higher USMLE Step 1 (p = 0.006), Step 2CK (p = 0.030), medical school GPA (p = 0.020) and class rank (p = 0.016). Interns rated as average had lower USMLE scores, GPA, and class rank than those rated as above average or outstanding; there were no significant differences between above average and outstanding interns. Higher rating in each of the ACGME core competencies was associated with better intern performance (p < 0.01).ConclusionsBetter performance as an intern was associated with higher USMLE scores, medical school GPA and class rank. When USMLE Step 1 reporting changes from numeric scores to pass/fail, residency programs can use other metrics to select medical students for interviews and employment.

Improving Our Ability to Predict Resident Applicant Performance: Validity Evidence for a Situational Judgment Test

Construct: We investigated whether a situational judgment test (SJT) designed to measure professionalism in physicians predicts residents’ performance on (a) Accreditation Council for Graduate Medical Education (ACGME) competencies and (b) a multisource professionalism assessment (MPA). Background: There is a consensus regarding the importance of assessing professionalism and interpersonal and communication skills in medical students, residents, and practicing physicians. Nonetheless, these noncognitive competencies are not well measured during medical education selection processes. One promising method for measuring these noncognitive competencies is the SJT. In a typical SJT, respondents are presented with written or video-based scenarios and asked to make choices from a set of alternative courses of action. Interpersonally oriented SJTs are commonly used for selection to medical schools in the United Kingdom and Belgium and for postgraduate selection of trainees to medical practice in Belgium, Singapore, Canada, and Australia. However, despite international evidence suggesting that SJTs are useful predictors of in-training performance, end-of-training performance, supervisory ratings of performance, and clinical skills licensing objective structured clinical examinations, the use of interpersonally oriented SJTs in residency settings in the United States has been infrequently investigated. The purpose of this study was to investigate whether residents’ performance on an SJT designed to measure professionalism-related competencies—conscientiousness, integrity, accountability, aspiring to excellence, teamwork, stress tolerance, and patient-centered care—predicts both their current and future performance as residents on two important but conceptually distinct criteria: ACGME competencies and the MPA. Approach: We developed an SJT to measure seven dimensions of professionalism. During calendar year 2017, 21 residency programs from 2 institutions administered the SJT. We conducted analyses to determine the validity of SJT and USMLE scores in predicting milestone performance in ACGME core competency domains and the MPA in June 2017 and 3 months later in September 2017 for the MPA and 1 year later, in June 2018, for ACGME domains. Results: At both periods, the SJT score predicted overall ACGME milestone performance (r = .13 and .17, respectively; p < .05) and MPA performance (r = .19 and .21, respectively; p < .05). In addition, the SJT predicted ACGME patient care, systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism competencies (r = .16, .15, .15, .17, and .16, respectively; p < .05) 1 year later. The SJT score contributed incremental validity over USMLE scores in predicting overall ACGME milestone performance (ΔR = .07) 1 year later and MPA performance (ΔR = .05) 3 months later. Conclusions: SJTs show promise as a method for assessing noncognitive attributes in residency program applicants. The SJT’s incremental validity to the USMLE series in this study underscores the importance of moving beyond these standardized tests to a more holistic review of candidates that includes both cognitive and noncognitive measures.

Graduate medical education competencies for international health electives: A qualitative study

Background: Residency programs offer international health electives (IHEs), providing multiple educational benefits. This study aimed to identify how IHEs fulfill the Accreditation Council for Graduate Medical Education (ACGME) core competencies.Methods: We conducted a thematic analysis of post-rotation reflective reports from residents who participated in IHEs through the Mayo International Health Program. We coded reports using a codebook created from the ACGME competencies. Using a constant comparative method, we identified significant themes within each competency.Results: Residents from 40 specialties participated in 377 IHEs in 56 countries from 2001 to 2014. Multiple themes were identified within each of the six ACGME core competencies: Patient Care and Procedural Skills (4), Medical Knowledge (5), Practice-Based Learning and Improvement (3), Interpersonal and Communication Skills (5), Professionalism (4), and Systems-Based Practice and Improvement (3). Themes included improving physical exam and procedural skills, providing care in resource-limited setting, gaining knowledge of tropical and non-tropical diseases, identifying socioeconomic determinants of health, engaging in the education of others, and increasing communication across cultures and multidisciplinary teams.Conclusions: Through IHEs, residents advanced their knowledge, skills, and attitudes in each of the six ACGME competencies. These data can be used for development of IHE competencies and milestones for resident assessment.

Science of health care delivery milestones for undergraduate medical education

BackgroundThe changing healthcare landscape requires physicians to develop new knowledge and skills such as high-value care, systems improvement, population health, and team-based care, which together may be referred to as the Science of Health Care Delivery (SHCD). To engender public trust and confidence, educators must be able to meaningfully assess physicians’ abilities in SHCD. We aimed to develop a novel set of SHCD milestones based on published Accreditation Council for Graduate Medical Education (ACGME) milestones that can be used by medical schools to assess medical students’ competence in SHCD.MethodsWe reviewed all ACGME milestones for 25 specialties available in September 2013. We used an iterative, qualitative process to group the ACGME milestones into SHCD content domains, from which SHCD milestones were derived. The SHCD milestones were categorized within the current ACGME core competencies and were also mapped to Association of American Medical Colleges’ Entrustable Professional Activities (AAMC EPAs).ResultsFifteen SHCD sub-competencies and corresponding milestones are provided, grouped within ACGME core competencies and mapped to multiple AAMC EPAs.ConclusionsThis novel set of milestones, grounded within the existing ACGME competencies, defines fundamental expectations within SHCD that can be used and adapted by medical schools in the assessment of medical students in this emerging curricular area. These milestones provide a blueprint for SHCD content and assessment as ongoing revisions to milestones and curricula occur.

The implementation of a practice management programme for family medicine residents in Qatar

Purpose: The aim of this study was to measure the effectiveness of introducing a full five-day practice management (PM) training workshop based on selected Accreditation Council for Graduate Medical Education (ACGME) competencies; professionalism, interpersonal and communication skills, practice-based learning and improvement (PBLI), and system-based practice. Methods: The study used pre-post study design. A total of 39 family medicine residents in Qatar were included in this study. The outcomes of interest were the level of change in the selected ACGME competencies. Pre- vs. post-workshop scores as well as change in scores of quarterly formative assessment were analysed using paired T-test. Results: The overall improvement in post-programme scores compared to pre-programme scores was 9.8% (p-value < 0.001). The PGY1 Group showed the most significant improvement with a score difference of 18.6% (p-value < 0.001). In self-assessment of skills, the main improvement was in writing objectives and time management skills (p-value < 0.001). The residents showed greater improvements in scores related to communication skills specifically in communicating effectively with patients (p-value = 0.032) as well as in specified skills among system-based practices; specifically in effectively using health resources (p-value < 0.001) and in co-ordinating patient care (p-value < 0.001). Conclusion: Implementing a full five-days PM training workshop had resulted in moderate improvements in residents’ score in selected ACGME competencies. A longer study on whether the effects of the programme on residents’ sustained performance and applicability in practice is required.

The Next Accreditation System in ophthalmology

The accreditation of graduate medical education through the evaluation of residency programs and the teaching hospitals that offer them in the United States is the primary mission of the Accreditation Council for Graduate Medical Education (ACGME). In 1999, the ACGME formulated the six ACGME competencies and, ten years later, developed a multi-year plan to restructure the accreditation process in order to assess educational outcomes. The result of these evolving efforts has been termed the Next Accreditation System (NAS). The stated goals of the NAS are 1) to enhance the ability of the peer-review system to prepare physicians for practice in the 21st century; 2) to accelerate the ACGME's movement toward accreditation on the basis of educational outcomes; and 3) to reduce the burden associated with the current structure and process-based approach. The NAS is an interesting and novel approach to re-engineer the GME accreditation process to become more equitable, fair, and transparent and less costly and burdensome, and to improve resident education and ultimately patient care. The new process will rely upon measurable and meaningful outcomes rather than simply structure and process assessments. Instead of the episodic program biopsies with site visitor reports, detailed program information forms, and formal residency review committee evaluations that characterized the old accreditation system, the NAS will be based upon annual reports of specific quantitative, trended, performance benchmarks; the ACGME milestones; and an institutional clinical competency committee. In addition, a separate but related specialty-specific Clinical Environment Learning Review (CLER) will be a more detailed examination of the learning environment and infrastructure. The CLER, however, will not have a direct role in the accreditation decision-making process of the NAS.

Senior Student Goal Setting During Subinternship: A Mixed-Methods Study

Background: New developments in Subinternship curricula attempt to establish self-directed learning skills that will translate into the 1st year of residency. However, we know little about how well senior medical students’ self-directed learning goals match with what is expected of them in residency. Purposes: We designed a mixed-methods study to examine the goals set by senior students at Georgia Health Sciences University on Pediatric Subinternship and to determine how those goals relate to the 6 Accreditation Council for Graduate Medical Education (ACGME) competencies. Methods: We used an iterative process to categorize self-directed learning goals on Pediatric Subinternships (n = 188 goals generated by 57 senior students) by (a) the 6 ACGME competencies and (b) general or specific goals. We used tests of association and multivariate modeling to compare goal categories by clinical site and time of year. Results: There were 56.3% of goals addressing patient care. Professionalism and systems-based practice goals were rare. Of the goals, 72% were general, but goals written by students at the newborn nursery and neonatal intensive care unit sites were significantly more likely to be specific than goals written by students on the general inpatient subinternship. Conclusions: The overwhelming majority of senior medical student goals on a Pediatric Subinternship are general and related to patient care. Students may need assistance with developing more specific goals in all 6 competencies. Our findings suggest that understanding and incorporating students’ learning goals may be important for enhancing the potential effectiveness of transition-to-residence curricula.

Development of a Global Health Curriculum for Family Medicine Based on ACGME Competencies

Background: With the popularity of global health among medical students and residents, family medicine (FM) residencies are developing pathways in global health. Curriculum based on Accreditation Council for Graduate Medical Education (ACGME) competencies adds rigor to the efforts. Description: We describe the adaptation of a comprehensive pediatric global health curriculum based on ACGME competencies for family medicine. The curriculum maps out goals, objectives, curricular elements, and evaluation modalities for each of the six competencies (medical knowledge, patient care, practice-based learning, professionalism, communication, and systems-based practice). A literature review, followed by an iterative process, guided the expansion of the pediatric curriculum and the prioritization of domains for FM. Input was sought from FM global health faculty at our 8 residencies, affiliated community faculty, and international health experts from across the United States who attended our workshop at a national FM global health meeting. The final product includes comprehensive competency-based curriculum, open-source resources, and evaluation modalities. The goals and objectives pertinent to all FM residents, and those specific to global health pathway residents and fellows, are outlined. Evaluation: The limiting and enabling factors of the curriculum implementation are presented. Conclusions: This global family medicine curriculum has added structure and rigor to our international electives in the department at the University of Minnesota. The competency-based curriculum is in the early stages of implementation and evaluation. It has already strengthened components of the residency learning experience for all residents. A robust evaluation is needed and requires monitoring pathway graduates and their career choices into the future. The curriculum is available for adoption by other FM residencies.

Educational Milestone Development in Phase II Specialties: Thoracic Surgery

To move toward a competency-based residency curriculum, the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project will use educational Milestones to assess residents' acquisition of competence for unsupervised practice, and will require measures of educational program effectiveness by assessing whether residents achieve certain specialty-specific Milestones in the 6 ACGME competencies. In January 2012, the American Board of Thoracic Surgery (ABTS) and the ACGME jointly formed a working group and charged it with developing the Thoracic Surgery Milestones. The development of the Milestones come at an important time, as the curricular and training paradigms in cardiothoracic surgery (CTS) have changed in recent years, and the Milestones will also be used to assess the success of these important changes.

Educational Milestone Development for Transitional Year Residency Training

The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project has shifted the focus for accrediting residency training programs from structure and process to documented outcomes. A central part of the ACGME's Next Accreditation System (NAS) is “articulating milestones of competency development in each discipline.”1 Resident achievement of educational Milestones will be an indicator of the educational effectiveness of residency programs. Most specialties have developed their Milestones through a collaborative effort involving representatives from the ACGME, the pertinent American Board of Medical Specialties (ABMS) organization, the pertinent professional specialty society, and the pertinent program directors' association. In contrast, the approach was quite different for Transitional Year (TY) residency programs, which comprise only 1 year of accredited postgraduate medical education, where there is no corresponding ABMS board certification entity or professional specialty society. In addition, graduates of TY training programs are not expected to demonstrate sufficient competency to enter the independent practice of medicine, as is the case with other specialty (categorical) residency programs.

Development of the Anesthesiology Educational Milestones

In the Next Accreditation System, resident performance and progression assessed through educational Milestones will be used as 1 of a number of quality indicators to evaluate the educational effectiveness of residency programs. The Anesthesiology Milestones will be used to measure the success of individual anesthesiology residents in achieving expected goals of training, and the effectiveness of the residency program will in part be evaluated based on aggregated Milestone performance data. Box Members of the Anesthesiology Milestone Working Group Deborah J. Culley, MD, Brigham and Women's Hospital, Chair Neal Cohen, MD, MPH, MS, University of California, San Francisco Steven Hall, MD, FAAP, Northwestern University Catherine Kuhn, MD, Duke University Loraine Lewis, EdD, RD, Executive Director, Anesthesiology RRC Linda Mason, MD, Loma Linda University Steven P. Nestler, PhD, Accreditation Council for Graduate Medical Education Consultant Rita M. Patel, MD, University of Pittsburgh Scott A. Schartel, DO, Temple University Brian Waldschmidt, MD, Resident Member, University of California, San Francisco Mark Warner, MD, Mayo Clinic Margaret Wood, MD, Columbia University College of Physicians and Surgeons

Organization of the Educational Milestones for Use in the Assessment of Educational Outcomes

Organization of the Educational Milestones for Use in the Assessment of Educational Outcomes

Internal medicine rounding practices and the accreditation council for graduate medical education core competencies

The Accreditation Council for Graduate Medical Education (ACGME) has established the requirement for residency programs to assess trainees' competencies in 6 core domains (patient care, medical knowledge, practice-based learning, interpersonal skills, professionalism, and systems-based practice). As attending rounds serve as a primary means for educating trainees at academic medical centers, our study aimed to identify current rounding practices and attending physician perceived capacity of different rounding models to promote teaching within the ACGME core competencies. We disseminated a 24-question survey electronically using educational and hospital medicine leadership mailing lists. We assessed attending physician demographics and the frequency with which they used various rounding models, as defined by the location of the discussion of the patient and care plan: bedside rounds (BR), hallway rounds (HR), and card-flipping rounds (CFR). Using the ACGME framework, we assessed the perceived educational value of each model. We received 153 completed surveys from attending physicians representing 34 institutions. HR was used most frequently for both new and established patients (61% and 43%), followed by CFR for established patients (36%) and BR for new patients (22%). Most attending physicians indicated that BR and HR were superior to CFR in promoting the following ACGME competencies: patient care, systems-based practice, professionalism, and interpersonal skills. HR is the most commonly employed rounding model. BR and HR are perceived to be valuable for teaching patient care, systems-based practice, professionalism, and interpersonal skills. CFR remains prevalent despite its perceived inferiority in promoting teaching across most of the ACGME core competencies.

On Volunteerism and Orthopaedics

Sometimes give of your services for nothing. And if the opportunity for serving a stranger in financial straits, give full assistance to all such. For wherever the art of medicine is loved, there is also a love of humanity—Hippocrates As the quotation above suggests, the selfless giving of one’s services and time has been recommended by generations of medical leaders since medicine’s earliest emergence as a paid profession. Whether such recommendations are prescriptive (i.e., what a physician should do if he or she is so inclined) or descriptive (i.e., what a physician is obligated to do, given his or her skills, as part of being a physician) has long been a subject of debate. The philosophical center of the debate is whether health care is a “right”—regardless of one’s ability to pay for it or deliver himself or herself to a physician. For if it is indeed a “right,” we are obligated to provide care to all. One man’s right is another man’s moral and ethical obligation. In this spirit, a recent American Orthopaedic Association (AOA) symposium and round table discussion (at the 2012 annual meeting) explored whether volunteerism should be considered a “core competency” and, if so, how we might implement it as we do the other competencies outlined by the Accreditation Council for Graduate Medical Education (ACGME). It is our opinion that a careful reading of the currently accepted ACGME competencies indicates that volunteerism clearly falls under the “professionalism” umbrella and should be considered part of what we must do (and must teach) to be (and to produce) complete, competent orthopaedic surgeons. In an on-site survey, the audience felt strongly that role modeling by faculty is an important predictor of resident behavior. Although most of the audience felt neutral about incorporating an international elective in a resident curriculum, …

Are Duty Hour Regulations Promoting a Culture of Dishonesty Among Resident Physicians?

Are Duty Hour Regulations Promoting a Culture of Dishonesty Among Resident Physicians?

Cytopathology fellowship outcomes assessment

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for oversight of pathology residency and fellowship organizations in the United States. Residents must have successfully completed their training in an ACGME-accredited or Royal College of Physicians and Surgeons of Canada-accredited residency to be eligible to take the American Board of Pathology (ABP) examinations. For subspecialties like cytopathology, only ACGME-accredited fellowships are accepted. The ACGME is undergoing major restructuring with a shift to continuous accreditation and outcomes assessment, the “Next Accreditation System” (NAS). With the NAS, site visits will be extended to 10 years for those individual pathology and fellowship programs that are performing well. The episodic “biopsy” model for accredited programs will be replaced by annual data collection, and program information forms will be replaced by self-studies. Each ACGME review committee will monitor the program data and trends and will determine whether the program needs to submit additional data or take action. The annual data will include resident and faculty surveys, case log information, scholarly activity, and educational milestones data. The Milestones project is the keystone of the NAS, requiring discernible developmental stages in attaining proficiency at established times during training. The educational milestones are based on the six ACGME competencies, planned in a systematically progressive framework. Milestones for the pathology resident are now posted in draft form on the ACGME website, and those for cytopathology fellows are in draft form but not published at this time. Each milestone is arranged in numbered levels, with level 1 representing most fellows at the beginning of training, level 4 representing the graduating fellow target, and level 5 being aspirational or representative of a cytopathologist in practice several years. The fellow interpretive and diagnostic knowledge milestones at level 4 will most likely be worded to state that fellows accurately diagnose most cytology samples. The ACGME revised program requirements for cytopathology that are effective July 1, 2013 specifically state that cytopathology fellows must demonstrate diagnostic proficiency and that they must demonstrate competence in the application of additional diagnostic adjuncts, including molecular testing. Fellows must evaluate at least