Accreditation Council For Graduate Medical Education Core Competencies Research Articles

Prioritizing Health Literacy Educational Objectives for Pediatric Residents – A Delphi Study

ObjectiveChildren of caregivers with limited health literacy are at risk of poorer health outcomes. Thus, health literacy-informed communication tools are critical to achieving a more equitable health system. However, there is no agreement on the health literacy skills pediatric residents should attain. We used Delphi methodology to establish consensus on health literacy objectives to inform development of a pediatric resident curriculum. MethodsOur Delphi panel participated in three rounds of anonymous surveys to rank the importance of health literacy objectives in pediatric resident education. Consensus was defined as ≥70% of panelists identifying an objective as essential or 100% agreeing an objective was recommended or essential. ResultsThirteen pediatric health literacy experts comprised a racially, geographically, and professionally-diverse panel. After three survey rounds, 27 of the initial 65 objectives met consensus. All final objectives aligned with Accreditation Council for Graduate Medical Education (ACGME) core competencies. ConclusionsA panel of pediatric health literacy experts established consensus on health literacy objectives specific to pediatric resident training. These prioritized objectives align with ACGME core competencies, as well as evidence-based strategies like teach-back, and newer considerations like addressing organizational health literacy. They should inform future health literacy curricula and assessment within pediatric residency programs.

Calcium Channel Blocker Overdose.

Emergency medicine residents and medical students on emergency medicine rotation. Calcium channel blocker (CCB) overdoses can be severe with potentially serious adverse outcomes. CCBs work by blocking the calcium channels on smooth and cardiac muscle tissue. At low dose ranges, dihydropyridine CCBs (such as nifedipine, amlodipine, and nicardipine) block the L-type calcium receptors in the peripheral vasculature, whereas non-dihydropyridine CCBs (such as: verapamil and diltiazem) affect the L-type calcium receptors in the myocardium.1 Because of this distinction, dihydropyridine CCB toxicity manifests as arterial vasodilation and non-dihydropyridine CCB toxicity is associated with cardiac manifestations such as bradycardia and negative inotropy.2 It is important to note that in high concentrations (such as in overdoses), CCBs lose specificity for their specific receptors and can show all the manifestations of toxicity such as bradycardia, peripheral vasodilation, and hypotension. Patients can develop both vasoplegic shock from peripheral vasodilation and cardiogenic shock. This is a high acuity low occurrence case with infrequently used but specific treatments, and thus this case provides educational value. At the end of this oral board session, examinees will: (1) demonstrate ability to evaluate a patient with undifferentiated shock with bradycardia and discuss the differential diagnosis, (2) recognize the signs and symptoms of calcium channel blocker overdose, (3) demonstrate ability to manage treatment of a patient with calcium channel overdose. This oral board case followed the standard American Board of Emergency Medicine-style case in a tertiary care hospital with access to all specialists and resources needed. This case was tested using 12 resident volunteers ranging from PGY 1-2 in an ACGME (Accreditation Council for Graduate Medical Education) accredited emergency medicine residency program. Immediate feedback was solicited both from the learners and from the evaluators following the debriefing session. Residents were asked to evaluate the educational value of the case using a 1-5 Likert scale (5 being excellent). Evaluators were asked to score the residents using the ACGME core competencies with a scale of 1-8, 1-4 being unacceptable and 5-8 being acceptable. Seven PGY1 residents and five PGY2 residents, thus twelve residents in total, completed the case. The average score was 5.10/8. Three residents missed zero critical actions. The most common critical action missed was consulting cardiology or cardiothoracic surgery for circulatory support options. Many residents failed to recognize that the patient did not have a perfusing blood pressure at the beginning of the case and did not start CPR. Although most residents recognized the patient's hemodynamic collapse was from a calcium channel blocker overdose, most did not know the treatment for this beyond atropine and intravenous fluids.The learners rated the educational value of the case as 4.9/5. Seven residents reported that the case definitely increased their medical knowledge; five residents reported that it somewhat increased their medical knowledge. All residents rated the case as helpful in preparing to manage this medical condition. The educational content from this case was effective. This is a high acuity low occurrence case that has unique treatments that are not commonly used. This makes this case excellent for practice and discussion. We learned during implementation that this case has a high degree of difficulty compared to other cases, and junior learners will need more prompting. It is also important for the proctor to keep the case moving because there is a lot to cover in the allotted amount of time. Calcium channel blocker overdose, toxicology.

Virtual Learning and Assessment in Rheumatology Fellowship Training: Objective Structured Clinical Examination Revisited.

With the onset of the COVID-19 pandemic, an annual multi-institutional face-to-face rheumatology objective structured clinical examination (ROSCE) was transformed into a virtual format. The educational goals of the virtual ROSCE (vROSCE) were to reproduce the educational value of the previous in-person ROSCE, providing a valuable formative assessment of rheumatology training activities encompassing the 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies for fellows-in-training (FITs). This article describes the novel design, feasibility, and stakeholder value of a vROSCE. Through an established collaboration of 5 rheumatology fellowship training programs, in February 2021, a vROSCE was created and conducted using a Zoom platform. Station development included learning objectives, FIT instructions, faculty proctor instructions, and a checklist by which to provide structured formative feedback. An anonymous, optional web-based survey was sent to FIT participants to evaluate the experience. Twenty-three rheumatology FITs from 5 institutions successfully rotated through 6 stations in the vROSCE. Immediate feedback was given to each FIT using standardized rubrics structured around ACGME core competencies. A total of 65% of FITs (15 of 23) responded to the survey, and 93% of survey respondents agreed or strongly agreed that the vROSCE was a helpful educational activity and identified individualized opportunities for improvement. A vROSCE is an innovative, feasible, valuable, and well-received educational technology tool. The vROSCE enriched rheumatology FITs' education and offered collaborative learning experiences across institutions.

Analysis of Taiwan Emergency Physicians’ Core Competencies Based on ACGME Criteria

The development of physicians’ core competency is related to the quality of medical practice. Accordingly, knowing how to cultivate and evaluate core competency is an important issue for medical education and management. This study used the comprehensive core competency framework proposed by the Accreditation Council for Graduate Medical Education (ACGME) and employed fuzzy AHP (FAHP) and DEMANTEL methods to analyze the weight and priority, as well as the cause-and-effect cluster. The FAHP analysis yielded the following rankings of factors’ importance: (1) patient care (C1; 27.83%), (2) medical knowledge (C2; 20.77%), (3) professionalism (C5; 17.93%), (4) interpersonal and communication skills (C4; 17.41%), (5) practice-based learning and improvement (C3; 15.52%), and (6) systems-based practice (C6; 8.233%). In terms of the DEMANTEL, the effect cluster included patient care (C1), professionalism (C5) and systems-based practice (C6), and the cause cluster included medical knowledge (C2), practice-based learning and improvement (C3), and interpersonal and communication skills (C4). The findings showed that patient care (C1) results from attitudes, patience, and the other five ACGME Core Competencies. Furthermore, emergency physicians’ development also requires humanities and ethics training and practice to ensure practice-based learning (C3). This study demonstrates the importance of various factors in developing emergency physicians’ core competencies, and the findings may provide a reference for future attempts at such competency development.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Using a Milestone Framework for Assessing Resident, Fellow, and Faculty Competence in Diversity, Equity, and Inclusion.

Graduating residents and fellows who can competently provide equitable and inclusive care to a diverse patient population requires data to monitor progress and outcomes. This data must be continuously gathered and used to guide improvements at the individual program level and at the sponsoring institution level for trainee and faculty growth and development. Recognizing the need for data, the Accreditation Council for Graduate Medical Education (ACGME) updated its 2021 annual Resident/Fellow and Faculty Surveys to include items related to equity and inclusion. Yet, accessible data on the structural competency level of our residents and faculty specific to the areas of health equity, social responsibility, diversity, inclusion, and social determinants of health is limited.1Our aim was to develop and implement a quick, evidence-based, structural competency tool to monitor trainee and faculty proficiency over time. A literature review was completed to identify key competency elements. To facilitate implementation, we framed our assessment to parallel the structure and format of the ACGME's core competency milestone model. Literature-identified elements were plotted in each of the core competency domains with progression delineated across 5 levels resulting in a comprehensive 8-page milestone document. The milestone was then iteratively revised by multiple stakeholders (experts in diversity, equity, and inclusion, ethics, and medical education; faculty; learners; program directors) to create an annotated and referenced 2-page master milestone and an abbreviated milestone with domain threads across levels (eg, Medical Knowledge) for inclusion within each graduate medical education (GME) program's required milestone assessment form and for faculty self-assessment. For example, an element in the domain of Patient Care level 3 (Identifies and incorporates mitigation strategies to address structural risks in patient care) progresses to level 4 (Develops and collaborates with patient on plan of care cognizant of patient's intersectionalites and its influences on their health care values, decisions…). In the Professionalism domain, level 3 (Reconciles personal beliefs and identities with professional role; develops strategies to mitigate own implicit biases; recognizes the contribution of bias to iatrogenic risk and health disparities) progresses to level 4 (Speaks up in the moment [allyship]; utilizes incident reporting mechanism to address microaggressions and/or lateral workplace violence).The milestone was approved by the Graduate Medical Education Committee (GMEC) for inclusion as a required formative trainee assessment in every program beginning in January 2021 and as a request for faculty to complete as a needs assessment. Data are not used for trainee progress (Clinical Competency Committee reviews) or annual faculty performance reviews. Trainee milestone data across programs revealed a consistent progression in the institutional average competence by year of training from 3.1 (postgraduate year [PGY]-1) to 4.4 (PGY-6). The same progression held within each residency and fellowship program. Faculty self-assessment (N>100) revealed that, on average, greater than 50% of the faculty perceived themselves to be at level 4 or higher: range between domains of 53%–79% at or above level 3 by competency domain with SD 1.1 to 1.7. Programs utilize the data as part of their annual program evaluations outlining measurable action steps. At the GMEC level, the data guide GME-wide diversity, equity, and inclusion educational sessions for trainees and faculty.This structural milestone innovation meets our need for data to monitor our trainees' and faculty's competence to guide ongoing program improvements. Formatted like existing ACGME Milestones, implementation within existing trainee competency assessment systems and/or as a faculty self-assessment is seamless, enhancing its utility, feasibility, and transferability. That said, we recognize that milestones are not static; the specific domain inclusions will need to evolve as we do on our equity journey.

Effect of resident and assessor gender on entrustment-based observational assessment in an internal medicine residency program

Background: Implicit gender bias leads to differences in assessment. Studies examining gender differences in resident milestone assessment data demonstrate variable results. The purpose of this study was to determine if observational entrustment scores differ by resident and assessor gender in a program of assessment based on discrete, observable skills. Methods: We analyzed overall entrustment scores and entrustment scores by Accreditation Council for Graduate Medical Education (ACGME) core competency for 238 residents (49% female) from 396 assessors (38% female) in one internal medicine residency program from July 2012 to June 2019. We conducted analyses at 1-12 months, 1-36 months, 1-6 months, 7-12 months, and 31-36 months. We used linear mixed-effect models to assess the role of resident and assessor gender, with resident-specific and assessor-specific random effect to account for repeated measures. Results: Statistically significant interactions existed between resident and assessor gender for overall entrustment at 1-12 months (p < 0.001), 1-36 months (p< 0.001), 1-6 months (p<0.001), 7-12 months (p=0.04), and 31-36 months (p<0.001). However, group differences were not statistically significant. In several instances an interaction was significant between resident and assessor gender by ACGME core competency, but there were no statistically significant group differences for all competencies at any time point. When applicable, subsequent analysis of main effect of resident or assessor gender independently of one another revealed no statistically significant differences. Conclusions: No significant differences in entrustment scores were found based on resident or assessor gender in our large, robust entrustment-based program of assessment. Determining the reasons for our findings may help identify ways to mitigate gender bias in assessment.

Advancing Fellowship Training in Selective Pathology.

Program requirements for Selective Pathology fellowships in the United States were established by the Accreditation Council for Graduate Medical Education (ACGME) in 2011 to govern fellowships providing advanced training in surgical pathology, focused anatomic pathology, or focused clinical pathology. Selective Pathology entered the ACGME's Next Accreditation System in 2015 with the introduction of the Selective Pathology Milestones 1.0, a set of benchmarks for evaluating fellow progress in each of the 6 ACGME core competencies. In 2019, the ACGME convened a work group for a planned periodic update to these milestones. To summarize changes to the Selective Pathology milestones. The study design featured expert opinion and survey. The Patient Care milestones for anatomic pathology-focused fellowships contain a renewed emphasis on both gross and microscopic examination, whereas for clinical pathology-focused fellowships, the emphasis is on interpretation of laboratory assays. The milestones for the non-Patient Care, non-Medical Knowledge competencies have been updated to a harmonized set of milestones designed to extend across all specialties and subspecialties. New to the milestones program is a supplemental guide that provides examples, suggested assessment tools, and references to aid in implementation. Public comments were supportive of the changes. The Milestones 2.0 are set for implementation in July 2021. Updates in the new milestones are aimed at facilitating training and harmonizing evaluation across subspecialties.

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.

Reimagining the Away Rotation: A 4-Week Virtual Subinternship in Urology

To develop and evaluate the first 4-week virtual subinternship in urology. Following a needs assessment, we established four course objectives: to teach foundational knowledge, assess students' abilities, highlight our program culture, and evaluate students' compatibility with our program. To meet these objectives, we developed a virtual curriculum that consisted of department conferences, small group didactic sessions, clinical/surgical encounters, interactive online modules, and informal sessions. At the conclusion of the subinternship, we sent anonymous surveys to students and physicians to measure success in meeting the course objectives. Student learning was measured using the framework of the Accreditation Council for Graduate Medical Education (ACGME) core competencies. The study was conducted at Columbia University Irving Medical Center, a tertiary care academic institution. Over a 2-month span, the virtual subinternship enrolled a total of 8 fourth-year medical students from 7 different medical schools in 5 different states. All residents and attending urologists in the Columbia University Department of Urology were involved in teaching. Overall, 100% of students and 63% of physicians rated the elective as "very good" or "excellent." The highest-rated components of the elective were the didactic curriculum and online modules. All course objectives were met, especially teaching foundational knowledge and highlighting program culture. Students reported high learning scores in all ACGME core competencies and urologic subspecialties, as well as increased confidence in managing a range of urologic conditions. The majority of students and physicians recommended incorporating virtual educational tools into future urology electives, particularly didactic sessions, online modules, and conferences/Grand Rounds presentations. A virtual subinternship in urology is a novel and successful model to enable student education, assessment, demonstration of program culture, and evaluation of student-program fit. This curriculum can serve as a template and springboard for the effective integration of virtual learning into surgical education.

Anesthesiology Residents' Experiences and Perspectives of Residency Training.

Anesthesiology residents' experiences and perspectives about their programs may be helpful in improving training. The goals of this repeated cross-sectional survey study are to determine: (1) the most important factors residents consider in choosing an anesthesiology residency, (2) the aspects of the clinical base year that best prepare residents for anesthesia clinical training, and what could be improved, (3) whether residents are satisfied with their anesthesiology residency and what their primary struggles are, and (4) whether residents believe their residency prepares them for proficiency in the 6 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and for independent practice. Anesthesiologists beginning their US residency training from 2013 to 2016 were invited to participate in anonymous, confidential, and voluntary self-administered online surveys. Resident cohort was defined by clinical anesthesia year 1, such that 9 survey administrations were included in this study-3 surveys for the 2013 and 2014 cohorts (clinical anesthesia years 1-3), 2 surveys for the 2015 cohort (clinical anesthesia years 1-2), and 1 survey for the 2016 cohort (clinical anesthesia year 1). The overall response rate was 36% (4707 responses to 12,929 invitations). On a 5-point Likert scale with 1 as "very unimportant" and 5 as "very important," quality of clinical experience (4.7-4.8 among the cohorts) and departmental commitment to education (4.3-4.5) were rated as the most important factors in anesthesiologists' choice of residency. Approximately 70% of first- and second-year residents agreed that their clinical base year prepared them well for anesthesiology residency, particularly clinical training experiences in critical care rotations, anesthesiology rotations, and surgery rotations/perioperative procedure management. Overall, residents were satisfied with their choice of anesthesiology specialty (4.4-4.5 on a 5-point scale among cohort-training levels) and their residency programs (4.0-4.1). The residency training experiences mostly met their expectations (3.8-4.0). Senior residents who reported any struggles highlighted academic more than interpersonal or technical difficulties. Senior residents generally agreed that the residency adequately prepared them for independent practice (4.1-4.4). Of the 6 ACGME Core Competencies, residents had the highest confidence in professionalism (4.7-4.9) and interpersonal and communication skills (4.6-4.8). Areas in residency that could be improved include the provision of an appropriate balance between education and service and allowance for sufficient time off to search and interview for a postresidency position. Anesthesiology residents in the United States indicated they most value quality of clinical training experiences and are generally satisfied with their choice of specialty and residency program.

A wider influence: The impact of formal humanitarian otology training on otology-neurotology fellows.

ObjectivesLong‐term commitment to humanitarian surgical outreach requires the opportunity, resources, and time to participate, but perhaps more importantly, it requires a preceding successful outreach experience. The Accreditation Council for Graduate Medical Education (ACGME) expects physician trainees to achieve six Core Competencies: patient care, medical knowledge, interpersonal and communication skills, professionalism, practice‐based learning and improvement, and systems‐based practice. This study investigates the challenges and benefits of a supervised humanitarian experience with a focus on ACGME Core Competencies, future global outreach, and commitment to education.Study designPhysician survey and program curriculum review.MethodsParticipants in a supervised humanitarian educational experience at a single Otology‐Neurotology Fellowship Program between the years of 2006 and 2019 were surveyed. Barriers to participation, challenges, benefits, prior and ongoing humanitarian efforts, and education endeavors were discussed.ResultsChallenges including time away from fellowship, logistical difficulties with Resident Review Committee recognition of operative case volume, and civil unrest were encountered. Benefits within all six ACGME Core Competencies were achieved. International collaboration with local providers, patients, and families with diverse socioeconomic and cultural backgrounds allowed bidirectional education while striving for safe, innovative solutions in resource‐poor environments.ConclusionsA supervised education experience with a sustainable humanitarian otology program offers Neurotology fellows an early positive experience near the end of their formal training. ACGME Professionalism goals were achieved through building collegial relationships with local otolaryngologists and staff, while fostering a sense of responsibility to assist those in developing nations. Participation correlated with an ongoing commitment to humanitarian efforts and education post‐fellowship.Level of Evidence4

Learning Abroad: Residents' Narratives of Clinical Experiences From a Global Health Elective.

While resident participation in global health (GH) rotations has grown, little is known about trainee perceptions of the personal value of these international clinical experiences and their importance to the objectives of GH training. We sought to better understand the clinical scenarios experienced during international rotations that residents perceived as most meaningful and the frequency of these experiences across scenarios and participating residents. Using the conceptual framework of Schön's reflection on action, we asked University of Minnesota GH track pediatric and internal medicine-pediatric residents to describe 10 clinical scenarios they found interesting or impactful during their 2016-2017 GH elective. We conducted a qualitative analysis of the deidentified resident narratives and mapped themes to the Accreditation Council for Graduate Medical Education (ACGME) competencies. All eligible residents (n = 13) participated, yielding 129 unique clinical scenarios from 7 countries. We identified 5 thematic groups: (1) addressing challenges in making diagnoses in resource-limited settings; (2) dealing with patient outcomes different from those expected in the United States; (3) encountering and managing diseases in a different clinical context; (4) encountering and managing diseases in a different cultural context; and (5) reflecting on learning and self-growth. Of the 129 unique clinical scenarios, 30% (n = 39) had not been previously experienced by participants. Across the 5 themes, all ACGME core competencies were addressed. Residents identified meaningful scenarios of their GH experiences that are relevant to the educational and clinical objectives of GH training.

Predicting Performance of First-Year Residents: Correlations Between Structured Interview, Licensure Exam, and Competency Scores in a Multi-Institutional Study.

To determine whether scores on structured interview (SI) questions designed to measure noncognitive competencies in physicians (1) predict subsequent first-year resident performance on Accreditation Council for Graduate Medical Education (ACGME) milestones and (2) add incremental validity over United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge scores in predicting performance. The authors developed 18 behavioral description questions to measure key noncognitive competencies (e.g., teamwork). In 2013-2015, 14 programs (13 residency, 1 fellowship) from 6 institutions used subsets of these questions in their selection processes. The authors conducted analyses to determine the validity of SI and USMLE scores in predicting first-year resident milestone performance in the ACGME's core competency domains and overall. SI scores predicted midyear and year-end overall performance (r = 0.18 and 0.19, respectively, P < .05) and year-end performance on patient care, interpersonal and communication skills, and professionalism competencies (r = 0.23, r = 0.22, and r = 0.20, respectively, P < .05). SI scores contributed incremental validity over USMLE scores in predicting year-end performance on patient care (ΔR = 0.05), interpersonal and communication skills (ΔR = 0.09), and professionalism (ΔR = 0.09; all P < .05). USMLE scores contributed incremental validity over SI scores in predicting year-end performance overall and on patient care and medical knowledge. SI scores predict first-year resident year-end performance in the interpersonal and communication skills, patient care, and professionalism competency domains. Future research should investigate whether SIs predict a range of clinically relevant outcomes.

A Content Analysis of the ACGME Specialty Milestones to Identify Performance Indicators Pertaining to the Development of Residents as Educators

Construct: For curriculum development purposes, this study examined how the development of residents as educators is reflected in the Accreditation Council for Graduate Medical Education (ACGME) Milestones. Background: Residents teach patients, families, medical students, physicians, and other health professionals during and beyond their training. Despite this expectation, it is unclear how the development of residents as educators is reflected in the specialty-specific Milestones. Approach: We performed a textual content analysis of 25 specialty Milestone documents available as downloads from the ACGME website in December 2015. Syntactical units of interest included developmental progressions that describe the development of educators over the course of residency training and 16 key terms identified during the analysis. We then categorized the terms by associated Milestone level, ACGME core competency, and targeted learner(s). Results: We identified 10 developmental progressions and 546 instances of the 16 key terms that describe the development of physician educators. The frequency of terms among specialties was quite variable (5–46 terms per specialty, Mdn = 21). The majority of education-related terms appeared at advanced Milestone levels; there were 139 (26%) such instances in Level 4 and 296 (54%) in Level 5. Education-related terms were identified in all six ACGME core competencies, with greatest frequency in Patient Care (157, 29%). Other residents were the learners most frequently targeted by education-related Milestones (211, 40%). Conclusions: The current ACGME Milestones largely imply that resident teaching is a high-level or aspirational goal, achieved without a clear or consistently assessed developmental progression. These findings run counter to the theoretical basis that underlies the development of the Milestones. Wide variation among specialties indicates lack of consensus around the ideal skill set of the resident educator and limits the utility of these documents for curriculum development in this domain.

What Every Graduating Resident Needs to Know About Quality Improvement and Patient Safety: A Content Analysis of 26 Sets of ACGME Milestones.

Quality improvement (QI) and patient safety (PS) are broadly relevant to the practice of medicine, but specialty-specific milestones demonstrate variable expectations for trainee competency in QI/PS. The purpose of this study was to develop a unifying portrait of QI/PS expectations for graduating residents irrespective of specialty. Milestones from 26 residency programs representing the 24 member boards of the American Board of Medical Specialties were downloaded from the Accreditation Council for Graduate Medical Education (ACGME) Web site in 2015. A codebook was generated by in-depth reading of all milestone sets by two authors. Using a content analytic approach, milestones were then coded by a single author, with a 25% sample double coded by another author. Descriptive statistics were used to characterize frequency counts. Of 612 total milestones, 249 (40.7%) made mention of QI/PS. A median 10 milestones per specialty (interquartile range, 5.25-11.75) mentioned QI/PS. There were 446 individual references to QI, 423 references to PS, and another 1,065 references to QI/PS-related concepts, including patient-centered care, cost-effective practice, documentation, equity, handoffs and care transitions, and teamwork. QI/PS references reflected expectations about both individual-level practice (531/869; 61.1%) and practice within a health care system (338/869; 38.9%). QI and PS references were linked to all six ACGME core competencies. Although there is variability in the emphasis placed on QI/PS across specialties, overall, QI/PS is reflected in more than 40% of residency milestones. Graduating residents in all specialties are expected to demonstrate competence in QI, PS, and multiple related concepts.

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.

New Roadmap for the Journey From Internist to Rheumatologist.

Measurement is necessary to gauge improvement. US training programs have not previously used shared standards to assess trainees' mastery of the knowledge, skills, and attitudes necessary to practice rheumatology competently. In 2014, the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System began requiring semiannual evaluation of all medicine subspecialty fellows on 23 internal medicine subspecialty reporting milestones. Since these reporting milestones are not subspecialty specific, rheumatology curricular milestones were needed to guide rheumatology fellowship training programs and fellows on the training journey from internist to rheumatologist. Rheumatology curricular milestones were collaboratively composed by expanding the internal medicine reporting milestones to delineate the specific targets of rheumatology fellowship training within 6 ACGME core competencies. The 2006 American College of Rheumatology core curriculum for rheumatology training programs was updated. A total of 80 rheumatology curricular milestones were created, defining progressive learning through training; most focus on patient care and medical knowledge. The core curriculum update incorporates the new curricular milestones and rheumatology entrustable professional activities. Rheumatology curricular milestones are now available for implementation by rheumatology fellowship training programs, providing a clear roadmap for specific training goals and a guide to track each fellow's achievement over a 2-year training period. The comprehensive core curriculum delineates the essential breadth of knowledge, skills, and attitudes that define rheumatology, and provides a guide for educational activities during fellowship training. These guiding documents are now used to train and assess fellows as they prepare for independent rheumatology practice as the next generation of rheumatologists.

Cleft Lip Standardized Patient Examinations: The Role in Plastic Surgery Resident Education.

Our institution has incorporated the use of objective structured clinical examinations (OSCE) in our residency curriculum. The OSCE provides trainee education and evaluation while addressing the six Accreditation Council for Graduate Medical Education (ACGME) core competencies required within training programs. We report our program's experience with the first cleft OSCE ever conducted. A validated method for administration of OSCEs currently used at our medical school was utilized for residents in postgraduate years (PGYs) 3 through 6. The video-recorded patient encounter involved a 1-month-old newborn with a unilateral cleft lip and palate and used standardized patient actors as parents. A post-encounter written exam assessed medical knowledge. A questionnaire regarding the utility of the exercise was administered to residents after the OSCE. Results were evaluated using analysis of variance (P < .05). There was a positive correlation with increasing level of training in terms of medical knowledge (P < .04). Residents in PGY-3 and PGY-4 demonstrated lower understanding of the surgical markings and details of the lip repair compared with those in PGY-5 and PGY-6 (P < .03). All residents performed similarly on evaluation of the remaining ACGME core competencies. All residents agreed that this was a realistic and useful encounter. Results of our cleft OSCE demonstrate that medical knowledge regarding the evaluation, management, and surgical repair of patients is less in midlevel residents. All residents expressed an interest in earlier exposure to pediatric patients in the training period. Although a cleft OSCE does not replace clinical rotations, it is a valuable adjunct to training and evaluation of trainees, particularly for junior residents.