copyright hershey s. bell, md 2002 strategies for teaching and integrating the new competencies into...
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Copyright Hershey S. Bell, MD 2002
Strategies for Teaching and Integrating the New Competencies
into Your Curriculum
Strategies for Teaching and Integrating the New Competencies
into Your Curriculum
A Call For Action
Hershey S. Bell, MD, FAAFPA Call For Action
Hershey S. Bell, MD, FAAFP
Copyright Hershey S. Bell, MD 2002
PhilosophyPhilosophy
A system of beliefs and principles that guide questions, answers,
decisions and actions
Copyright Hershey S. Bell, MD 2002
Proposed Philosophy for Medical Education
Proposed Philosophy for Medical Education
• The intent and outcome of Medical Education should be clear to all involved
• Every learner and teacher within Medical Education should be clear on their accountability in the system
• Medical Education should foster the development of effective relationships
• Medical Education should be safe for all those involved
Copyright Hershey S. Bell, MD 2002
Competency-Based EducationCompetency-Based Education
• Provides clarity of learning direction for both faculty and residents
• Creates accountability around the process and outcomes of learning
• Requires relationship-based teacher/learner interaction
• Provides an opportunity for added safety in education
Copyright Hershey S. Bell, MD 2002
CarrollCarroll
Re-defined aptitude as the time that it takes to achieve competency
AptitudeAptitude
Copyright Hershey S. Bell, MD 2002
BloomBloom
Suggested that if Carroll’s notion of aptitude is correct, then it must be theoretically possible to manipulate the learning environment such that
every student can achieve competency given enough time.
Copyright Hershey S. Bell, MD 2002
Competency Based EducationCompetency Based Education
Competencies
Instruction
Formative Evaluation
Remediation
Educational Dx and Rx
Copyright Hershey S. Bell, MD 2002
CompetencyCompetency
The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice for the benefit of the individual and the community
being served.
Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002
Copyright Hershey S. Bell, MD 2002
DefinitionsDefinitions
• Competency– The minimum level required to practice one’s
craft
• Mastery– A pursuit of excellence above and beyond
competence (Dreyfus Model)
Copyright Hershey S. Bell, MD 2002
Competency and MasteryCompetency and Mastery
Competency
The Road to MasteryStart
Copyright Hershey S. Bell, MD 2002
CLARITYCLARITY
Copyright Hershey S. Bell, MD 2002
Validation for the STFM Competencies
Validation for the STFM Competencies
• Bauer, Jonas, Cass and Bell, 1989
• Literature Review
• STFM Task Force on Competency-Based Education, 1992-1997– Focus Groups– Delphi Panels
• Hunterdon Medical Center Faculty, 1989-1996
Copyright Hershey S. Bell, MD 2002
STFM Task Force on Competency-Based Education
STFM Task Force on Competency-Based Education
• 5 Realms of Competency– Clinical Acumen (CA), Interpersonal Skills (IS),
Organizational Skills (OS), Business Practice (BP), Growth and Development (GD)
• Integrated Competency Paradigm– Teaching can occur in any realm, or in any combination
of realms and be of value
Bell HS, Kozakowski SM, Winter RO. Competency-based education in family practice. Fam Med 1997;29(10):701-4
Copyright Hershey S. Bell, MD 2002
The Integrated Competency ModelThe Integrated Competency Model
GD
OS BP
IS CA
Copyright Hershey S. Bell, MD 2002
Competencies for the Emerging Practice Environment
Competencies for the Emerging Practice Environment
• Health care system overview
• Population-based care
• Quality measurement and improvement
• Medical Management
• Preventive Care
• Physician-Patient Communication
• Ethics
• Teamwork and Collaboration
• Information management and technology
• Practice Management
Halpern R, Lee MY, Boulter PR, Phillips RR. Academic Medicine 2001
Copyright Hershey S. Bell, MD 2002
ACGME General CompetenciesACGME General Competencies
• Patient Care (CA)• Medical Knowledge• Practice Based
Learning and Improvement (OS)
• Interpersonal and Communication Skills (IS)
• Professionalism (GD)• Systems-Based
Practice (BP)
• Osteopathic Principles and Practice
Copyright Hershey S. Bell, MD 2002
Specific CompetenciesSpecific Competencies
• Patient Care– communicate
effectively
– gather essential and accurate information
– make informed decisions
– carry out patient management plans
• Patient Care (cont’d)– counsel and educate– use information
technology– perform procedures
competently– preventing health
problems or maintain health
– work with health care professionals
Copyright Hershey S. Bell, MD 2002
Specific CompetenciesSpecific Competencies
• Medical Knowledge– investigatory and
analytic thinking
– apply the basic and clinically supportive sciences
• Practice Based Learning and Improvement– perform practice-based
improvement
– evidence
– population
Copyright Hershey S. Bell, MD 2002
Specific CompetenciesSpecific Competencies
• Practice Based Learning and Improvement (cont’d)
– appraisal of clinical studies
– information technology to manage information
– facilitate the learning of others
• Systems-Based Practice– systems thinking
– medical practice and delivery systems
– cost-effective health care
– quality
– partnership
Copyright Hershey S. Bell, MD 2002
• Interpersonal and Communication Skills– therapeutic and
ethically sound relationship
– effective listening
– health care team
• Professionalism– respect, compassion,
integrity
– commitment to ethical principles
– sensitivity
Specific CompetenciesSpecific Competencies
Copyright Hershey S. Bell, MD 2002
• Osteopathic Principles and Practice– the body is a unit; the person is a unit of body, mind,
and spirit
– the body is capable of self-regulation, self-healing, and health maintenance
– structure and function are reciprocally interrelated
– rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function
Specific CompetenciesSpecific Competencies
Copyright Hershey S. Bell, MD 2002
Changing the Accreditation FocusChanging the Accreditation Focus
COMPLIANCE– Does the program
comply with the requirements?
– Does the program have established objectives and an organized curriculum?
– Does the program evaluate its residents and itself?
DEMONSTRATE– Does the program
achieve its objectives?
– What evidence can it provide that it does so?
– How does the program demonstrate continuous improvement?
From Dianne M. Hartmann, MD, University of Rochester
Copyright Hershey S. Bell, MD 2002
Competency Based EducationCompetency Based Education
Competencies
INSTRUCTION
Formative Evaluation
REMEDIATION
Educational Dx and Rx
Copyright Hershey S. Bell, MD 2002
Teaching Strategies: TypesTeaching Strategies: Types
• Group-based Instruction– Most acceptable and effective strategy for the
group as a whole (80/20 rule)
• Instructional Correctives/Remediation– Influenced by specific learning styles and needs
(corrects the teacher’s behavior)
Copyright Hershey S. Bell, MD 2002
...the only people for me are the mad ones, the ones who are mad to live, mad to talk, mad to be saved, desirous of everything at the same time,
the ones who never yawn or say a commonplace thing, but burn, burn, burn like fabulous yellow roman candles exploding like spiders across the
stars and in the middle you see the blue centerlight pop and everybody goes, "Awww!”
- Kerouac
Copyright Hershey S. Bell, MD 2002
Teaching Strategy ExamplesTeaching Strategy Examples
• Tufts Managing Care Curriculum• Integrating Improvement Competencies into UNC
Pediatric Residency Education• Innovations in Leadership: Professionalism and
Systems (Loyola)• Teaching Practice-Based Learning and
Improvement, Interpersonal and Communication Skills, and Systems Based Practice with a Senior Resident Seminar and Team Project (Mayo)
Copyright Hershey S. Bell, MD 2002
R.S.V.P.R.S.V.P.
• Recognize Success Via ImPlementation
www.acgme.org/outcome/implement/rsvp.asp
Copyright Hershey S. Bell, MD 2002
ACCOUNTABILITYACCOUNTABILITY
Copyright Hershey S. Bell, MD 2002
AccountabilityAccountability
• Definition• Learner’s Domain
– Accountable for choosing a curriculum– Accountable for Learning
• Teacher’s Domain– Accountable for Curriculum Implementation
(RRC)– Accountable for giving effective feedback– Accountable for Clinical Care
Copyright Hershey S. Bell, MD 2002
Clinical CareClinical Care
• The tasks of clinical care may be delegated– this is a critically important teaching strategy
• The accountability for clinical care may not be delegated– faculty are always accountable for clinical care
While residents may deliver care, faculty remain fully accountable for the care that is delivered
Copyright Hershey S. Bell, MD 2002
Competency Based EducationCompetency Based Education
Competencies
Instruction
FORMATIVE EVALUATION
Remediation
Educational Dx and Rx
Copyright Hershey S. Bell, MD 2002
Formative EvaluationFormative Evaluation
• Formative Evaluation is the coming together of the following 3 components for the teacher:– Feedback– Redirection based on the competencies of the
curriculum– Facilitate discovery through encouragement
Copyright Hershey S. Bell, MD 2002
FeedbackFeedback
KnownWorld
HiddenWorld
SecretWorld
UnknownWorld
Feedback
Revelation
Disclosure
KNOWN UNKNOWN
KNOWN
UNKNOWN
YOU
THEM
Copyright Hershey S. Bell, MD 2002
ACGME ToolboxACGME Toolbox
• 360 Degree• Chart Stimulated
Recall• Checklist• Global Rating• OSCE• Standardized Patient
Exam• Written Exam (MCQ)
• Procedure, Operative or Case Logs
• Patient Surveys• Portfolios• Record Review• Simulations/Models• Standardized Oral
Exam
Copyright Hershey S. Bell, MD 2002
Direct FlightDirect Flight
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Connecting FlightConnecting Flight
Copyright Hershey S. Bell, MD 2002
Going as far out of your way as is humanly possible
Going as far out of your way as is humanly possible
Copyright Hershey S. Bell, MD 2002
Some learners...Some learners...
• Take Direct Flights
• Take Connecting Flights
• Go as far out of their way as is humanly possible
Our challenge is to work effectively with all learners regardless of the particulars of
their specific journey
Copyright Hershey S. Bell, MD 2002
EncouragementEncouragement
• I believe in you
• I trust you
• I know you can handle this
• You are listened to
• You are cared for
• You are very important to me
Copyright Hershey S. Bell, MD 2002
Copyright Hershey S. Bell, MD 2002
RELATIONSHIPRELATIONSHIP
Copyright Hershey S. Bell, MD 2002
Kathleen N. LohrKathleen N. Lohr
“Quality measurement should involve both processes and outcomes of care; a focus on only one
will be a mistake. Today’s focus on outcomes management in the United States will not be the
answer to all of the quality problems likely to arise tomorrow.”
Copyright Hershey S. Bell, MD 2002
Formative versus Summative Evaluation
Formative versus Summative Evaluation
• Formative evaluation (forming the development of the learner) is central to CBE
• Summative evaluation (summarizing achievement) is not a component of CBE
• Evaluation (assigning a value) is entirely subjective, but is made most reliable and valid through examination of accurate and complete data
Copyright Hershey S. Bell, MD 2002
Summative Evaluation: In the Learner’s Domain*Summative Evaluation:
In the Learner’s Domain*• Safety emanates from relationship, hence
relationship building is critical• Clearly stated expectations ease the
formation of safe relationships• Non-judgmental respect for a learner’s
process eases the formation of safe relationships
* regarding educational accountability - performed on behalf of growth and development
Copyright Hershey S. Bell, MD 2002
The Johari Cycle*The Johari Cycle*
Feedback
Revelation and Disclosure
*Bell
Copyright Hershey S. Bell, MD 2002
Summative EvaluationSummative Evaluation
• When learner’s feel safe, they are more likely to revelate and disclose, hence learn and grow
• Ongoing formative evaluation must occur - both a teacher and a learner responsibility
• Dysfunctional learning must be addressed AND it must be addressed outside of this relationship
Copyright Hershey S. Bell, MD 2002
Summative Evaluation for Teachers*
Summative Evaluation for Teachers*
• Promotion and advancing responsibility
• Graduation
• Reference Letters
* regarding clinical accountability - performed on behalf of our covenant with society
Copyright Hershey S. Bell, MD 2002
SAFETYSAFETY
Copyright Hershey S. Bell, MD 2002
The experience of safety may be the single most important
determinant with respect to a student’s likelihood to learn and
grow
Copyright Hershey S. Bell, MD 2002
Lucian L. Leape, MDLucian L. Leape, MD
“Non-punitive means people are not punished for making mistakes - nothing more. It doesn’t mean that people are not punished for misconduct - nothing less. People should never be punished for errors - ever. The nonpunitive environment recognizes that no one (other than a psychopath) makes a
mistake on purpose and that human errors result from faulty systems, not from faulty people. The person who makes a mistake, like the injured patient, is the victim of a system
failure. It is the system that must be changed, not the individual.”
Copyright Hershey S. Bell, MD 2002
Realms of Safety for LearnersRealms of Safety for Learners
• Safe for the learner to ask questions• Safe for the learner to risk their thinking• Safe for the learner to practice new skills• Safe for the learner to challenge established
constructs• Safe for the learner to be seen as vulnerable• Safe learning environment - e.g. work hrs.• Patient safety
Copyright Hershey S. Bell, MD 2002
SummarySummary
• Clarity is achieved through definition of competency and thorough teaching
• Accountability is attended to by learners and teachers, but in different ways
• Attention to relationship allows for a focus on process as well as outcome
• Safety may be the most important issue to contend with
Copyright Hershey S. Bell, MD 2002