Comparison: Traditional vs. Outcome Project Educational Paradigms Craig McClure, MD Educational Outcomes Service Group University of Arizona December 2004

Current Problem Increasing public concerns with quality and safety. Variable patterns of care that are not based on medical science. Poor quality of interpersonal “service.” Public encounters difficulty in assessing physician competence (initial and continuing ) and judging quality.

The ACGME Mission To improve the quality of health care in the United States by ensuring and improving the quality of graduate medical educational experiences for physicians in training.

Problem Plus Mission ACGME responded to the challenge by changing focus to: How well do we learn what is being taught How well do we practice what we learn?

A new way of thinking Competency Structure & process How to change the educational and accreditation system from…

Program Goal OLD: goal was for the Program to comply with the written RRC Requirements NEW: the Program Director must determine if residents achieve the learning objectives set by the Program.

Curriculum Development OLD: Curriculum development follows the historical model (residents learn “X” because it’s always been included) NEW: Curriculum development follows the “Outcomes” model (residents must learn “X” to become a competent physician)

RRC Review OLD: “Minimal threshold” model: Program review identifies whether or not a program has the potential to educate residents NEW: Program Director must offer documentation that the residents achieve the learning objectives set by the Program.

Teaching Model OLD: Instructivist model (“facts” are transmitted from teachers to students) NEW: Interactive model: fosters reflective self- evaluation by the learner, learning experiences clearly aligned with expected competencies

Definition of Knowledge OLD: Knowledge is static, finite, linear, and private NEW: Knowledge is dynamic, open ended, multidimensional, and public

Epigrams OLD: Teacher is the “Sage on the stage” NEW: Teacher is the “Guide on the side”

Educational Experiences OLD: Geared to provide contact time with a variable set of clinical experiences by rotation NEW: The educational process focuses on developing and documenting competency with experiences directed at learner needs

Improving the Teaching Program OLD: The Program should have a process to evaluate residents and itself NEW: The Program Director must offer documentation of continuous improvement in the residency educational process

Educational Process OLD: It was sufficient that the Program have established goals, objectives and expose residents to organized curricular experiences with residents performing at the expected norm NEW: Criterion- referenced assessments translate into formative feedback loops to help the learner achieve competence

Other Outcome Characteristics

“Authentic” Justification for elements included in the curriculum is that competence as a practicing physician requires that skill, knowledge or attitude Evaluation is of the actual skill, knowledge or attitude used by practicing physicians

More Individualized A principle of a criteria-driven physician curriculum is that everyone can become competent with sufficient exposure Residents obtain skills at different rates with requirements for disparate learning experiences An optimal outcome-driven system would have an intake assessment followed by an individualized program of study

Reflection and Self-knowledge Critical Criteria for competence are provided to the learner Impetus for improvement arises from desire to narrow the gap between criteria and performance Accurate self-assessment is essential to the resident gauging personal performance