1. A Basic Guide to the ACGME General Competencies
You are receiving this slide presentation as a step in our department’s need to provide a faculty development program that will assist all faculty members, both paid and voluntary, to teach and assess each resident’s ability to competently practice emergency medicine within the guidelines set forth by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME is the body which approves all training programs for M.D.s. We must be able to demonstrate that we effectively teach and assess the competencies in order to retain our residency programs. Your knowledge of how to teach and assess is fundamental to our residency program and is the reason for this faculty development program.
A word to explain terminology. The ACGME has developed six competencies which are named the General Competencies. The Council of Residency Program Directors for Emergency Medicine (CORD) has defined these general competencies in terms of what emergency physicians do. These specific behaviors and abilities have been named the Core Competencies.
Adapted from the CORD website by:
Phil Levy, M.D. Gloria Kuhn, D.O.
Bob Wahl, M.D.
Wayne State University School of Medicine

2. Introduction Responsibility of the Program
Teach the ACGME General Competencies
Assess the resident’s achievement of competence in each of the Core Competencies before graduation
Faculty development
Every residency program is required to teach the ACGME General Competencies and assess each resident’s competence to practice medicine within the guidelines set forth by the language of these competencies. At graduation each Program Director attests to the competence of a graduate. The ability of the Program Director to state that a resident has achieved competency is dependent upon the faculty teaching the competencies and assessing the residents progression toward and achievement of the competencies prior to graduation. This does not mean that each resident is an expert in emergency medicine prior to graduation. Rather, it means that we believe that the resident can independently practice emergency medicine. It recognizes that physicians, including our graduates, will engage in life-long learning so that they continually expand their knowledge, improve their intellectual skills, and maintain and improve their procedural skills.
It is our duty as faculty to assist them in learning the competencies and ready them for the independent practice of emergency medicine. It is their duty to engage in learning and work towards attaining a level of knowledge and ability that will allow them to be recognized as competent.
One of the advantages of the ACGME Competencies is that both teachers and learners have responsibilities for a resident’s learning. It is therefore a contract between us as teachers, our department as an educational entity, and the residents we teach.
Faculty development is part of this contract; we can not teach what we don’t know.

3. Introduction Responsibility of the Faculty
Know what the Core Competencies are
Commit (be prepared) to teach them
Commit (be prepared) to assess a resident’s progression to competency in each of them
Faculty have three fundamental responsibilities:
Know the competencies, teach them, and assist in assessing a resident’s ability to competently practice them when caring for patients.

4. Faculty Development E-mail Staff meetings Faculty meetings
Information pertinent to your knowledge and understanding of the core competencies will be provided to you via:
Staff meetings
Faculty meetings
Distance learning
Three years ago we began a faculty development program to teach faculty about the ACGME Competencies. This program included short discussions during faculty and staff meetings, sending out messages and now by the use of distance learning.
We have continued to add new faculty to our department and we need to be sure that all faculty know about the competencies. Thus, we are beginning a distance education project for all our members, those who are new as well as those who have been in the department over the past years.

5. Gaining Medical knowledge
Clinical Experience : Most important aspect of training
Bedside teaching and learning transforms medical students into physicians
Medical students are not doctors. The most important, and the only way, to become a doctor is to see patients. It is bedside teaching and learning while seeing patients that transforms medical students into physicians.
We believe that it is the knowledge of our attending physicians (faculty) and their ability to teach residents that is the real strength of our educational programs. We also believe that it is the voluntary faculty, who work with the residents on the majority of shifts, and therefore have significant opportunity to contribute to bedside teaching.

6. Slides in this Series Define the competencies
Discuss meaning of the competencies
Faculty will be asked to attest that they have read the material, understand it, and commit to teach the competencies
After viewing this set of slides you will:
Know the six ACGME Competencies
Recognize how they have been defined for the specialty of emergency medicine by the Council of Residency Directors for Emergency Medicine
Understand some principles to help teach them
Know how the residency program and our department will assess the learning of the residents and determine their progression toward competency.
After viewing the slides you will be asked to attest to your having read about the competencies.

7. Request Faculty List the ACGME Core Competencies Sign attestation
Return to Sandra Garling
Fax ( attn Sandra Garling)
Hard copy
Read the slides including the notes, list the competencies on the attestation sheet which is attached, complete the evaluation and return both the attestation and evaluation sheets to Sandra Garling by , fax, or hard copy.

8. What Are the Core Competencies ?
Six approved by ACGME in February 1999
Patient Care
Medical Knowledge
Practice-Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-Based Practice
In 1999 the ACGME adopted a requirement that residents be competent in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. They called this the Outcomes Project. Many physicians felt that these were the skills we were already teaching. What is different about the Outcomes Project is that training programs are now required to demonstrate that they not only teach these skills, but that residents have actually learned them, are competent in using them, and actually demonstrate that competency when caring for patients.
This placed a burden on training programs to not only teach, but also provide effective assessment tools to determine competency. Finally, residency programs must be evaluated on their ability to teach and assess resident knowledge and behaviors.
The advantage of using these competencies is that residents must demonstrate that they practice within these guidelines. When the behavior of a resident is unacceptable regarding professional conduct, such as repeated lateness to work, we can demonstrate that they are not in compliance. While we have done that, the competencies of interpersonal and communication skills and professionalism are now convenient to teach and to hold residents accountable to achieve.

9. Definitions ACGME provided the general language
Each specialty provided the detailed definitions
The Council of EM Residency Directors (CORD) held a series of consensus conferences to define for our specialty
Intellectual and procedural skills
Behaviors
The ACGME provided general language regarding the competencies, but recognized that each medical specialty is unique in the knowledge and behaviors needed by their practitioners for the successful practice of their medical specialty.
To fulfill the need for detailed and specific definitions of the competencies, the Council of Residency Directors for Emergency Medicine (CORD) held a series of conferences to define what we expect our residents to be able to do upon graduation from residency. These expectations include knowledge, intellectual and procedural skills, and behaviors.
To a large extent, it makes the teaching of residents easier as they define what must be taught. The definitions of the competencies also inform residents what they must learn and how they must behave (standards) to successfully complete our program.

10. Why Adopt A Competency Based Model?
Creates objective criteria for evaluation
Core competencies
Holds programs/educators accountable
Demonstrates effectiveness of efforts
Holds residents accountable
We now have language that structures teaching and training. Success is no longer a mystery (subjective). Everyone knows where the bar has been set.

11. Current Reality
Programs must demonstrate provision of an educational experience that will ensure proficiency for all graduates in the core competencies
Programs must assess residents
Programs will be assessed
The ACGME now mandates that we begin to implement a program demonstrating not only how we teach but how we assess the residents attainment of the core competencies. We are moving from questions of what to teach, to determining how best to teach, and how to determine if learning has taken place. That means our program will need to prove that residents have learned the competencies and practice them. It also means that our program will have to have both internal and external evaluation over and above the Residency Review Committee for Emergency Medicine (RRC-EM) periodically evaluating the program.

12. Core Competencies Patient Care Medical Knowledge
Practice-Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-Based Practice
These are the six competencies.
Each will be defined and discussed in some detail. The definitions are taken from the consensus conferences held by CORD in 2002.

13. Definition of Competency Patient Care 1
Provision of timely, effective, appropriate and compassionate patient care
Patient care includes provision of timely, effective, appropriate, and compassionate patient care. There is an emphasis on timely, as emergency medicine requires that practitioners are often under time pressure to evaluate critically ill patients and initiate treatment, often before being able to obtain a full history. Furthermore, EM physicians at times see a large volume of patients and must appropriately manage their time.
Having this language is very helpful when explaining why residents are under time constraints in our departments.
Therefore, we need to see a progression, although gradual, in a resident’s ability to increase the number of patients they effectively evaluate and manage, as they move from year 1 to year 3 of the program.
1 King et al. AEM 2002;9:

14. Meaning Patient Care 1 The Resident:
Gathers accurate, essential information using all available sources
Integrates diagnostic information to form an appropriate differential diagnosis
We now have language that helps to define what effective patient care is. Determining what information to gather, where to find hard-to-find information, and finally to integrate it into a plan for diagnosis and treatment is an essential skill for emergency physicians and one that is difficult for residents to achieve. Residents must be able to do this. Faculty need to assist residents to learn this skill, and must see progressive improvement in this skill as they assess resident performance over time.
1 King et al. AEM 2002;9:

15. Meaning Patient Care 1 Implements an effective management plan
Including treatment, consultation, disposition and pt. education
Resident has the capacity to perform essential
diagnostic, and
therapeutic procedures
Residents must be able to provide all aspects of patient care from examining a patient to appropriate disposition by the time of graduation. They must be able to perform the procedures which our specialty has listed as being within our practice of medicine.
Simpler cases and procedures will be expected of more junior residents. More senior residents must be able to articulate a plan for even complex patients prior to graduation.
1 King et al. AEM 2002;9:

16. Meaning Patient Care 1 Prioritize and stabilize
Simultaneously
Prioritize and stabilize
multiple patients
Perform other responsibilities
As residents progress through their training they must be able to manage multiple patients in an effective manner. In the latter part of their training they must be able to perform other responsibilities, such as leading resuscitations and effectively supervising junior residents. It is necessary for us to teach them these skills as many will not learn them without our teaching.
Each resident will begin to gain these skills and become more proficient in their use at different times in the training period, but all must be able to do this prior to graduation. Some of the language that we will begin to use in our evaluation discussions is “have you seen progression” in the resident’s capability as their training continues.
1 King et al. AEM 2002;9:

17. Definition of Competency Medical Knowledge 1
Use medical knowledge for clinical problem solving and decision-making
Identify life-threatening conditions
Formulate an appropriate differential diagnosis
1Wagner MJ AEM 2002, 9:1236–1241
The next two slides define the competency of medical knowledge. This definition is self-explanatory, but difficult for all residents to attain, particularly in the area of differential diagnosis.
Often, residents who are struggling in the program may even have trouble recognizing “sick” from “not sick” patients. This comment is not infrequently heard during our evaluation sessions when discussing residents who are not progressing as expected.

18. Meaning Medical Knowledge 1
Specific immediate recall of information for care of critical patients
Understand use of medical resources for immediate care
Apply information to undifferentiated patient presentations
1Wagner MJ AEM 2002, 9:1236–1241
Wagner MJ AEM 2002, 9:1236–1241
When you are ready, go to the next slide.

19. Gaining Medical Knowledge
Didactic knowledge
Classroom
Independent study
Bedside learning
We should hold residents to the standard of learning in the classroom, studying independently to increase their knowledge, and being ready to learn from supervising physicians when they see patients.
We need to hold ourselves to the standard of teaching at the bedside, being ready to explain principles they don’t understand, and be willing to explain our decision making. This takes both patience and understanding on our part, but it is what makes us good clinical teachers.

20. Definition of Competency Practice-Based Learning and Improvement 1
Understand patient care practices and assimilate necessary components for improvement
In very simple terms, this means learning as a result of seeing patients and improving as a result of experience. It is what we must do and what we must help residents to learn how to do.
1 Hayden et al. AEM 2002;9:

21. Meaning Practice-Based Learning and Improvement 1
Use scientific evidence related to patient’s health problems and the larger population from which they are drawn
Scrutinize and critically interpret medical literature
Using existing evidence to care for patients, as well as our own clinical experience, is what our department tries to make sure we do as we discuss guidelines and policies during staff meetings. We do it when we question each other or send articles by on our list serve.
We need to communicate this use of evidence to our residents as they learn and practice. We need to allow residents to ask “How do you know?” without them feeling afraid. We need to be able to ask residents “how do you know?” without them feeling defensive. Our reasoning may be based upon the literature, or it may be based upon past clinical experience. Experienced and capable doctors use both when examining and treating patients. What we need to do is tell residents what information we are using to make a decision and where that information came from.
This is really the culture of teaching and learning. We need to be sure that this culture is present in the classroom, at journal club, in our staff meetings, and most importantly at the bedside.
1 Hayden et al. AEM 2002;9:

22. Meaning Practice-Based Learning and Improvement 1
Able to utilize information technology to effect patient care and education
Able to facilitate the education of colleagues and students
Medicine and how we practice seems to change daily. It is a fact of our lives and a fact of the residents’ lives.
Residents may even be better at incorporating chang than faculty in some cases. Allowing them to teach us demonstrates the exchange of information among colleagues. Teaching an attending physician something new may even be what gives a resident having difficulties in the program the courage and encouragement to keep going.
1 Hayden et al. AEM 2002;9:

23. Definition of Competency Interpersonal and Communication Skills 1
Able to conduct an effective information exchange with patients, their families and medical colleagues
The definition of effective interpersonal and communication skills has, up until now, been vague. Now we have language which helps to define what this means. This will become more evident as you look at the next slides.
1 Hobgood et al. AEM 2002;9:

24. Meaning Interpersonal and Communication Skills 1
Appropriate language
Ability to read body language of patient/families
Find an interpreter
Ask for questions
Repeat information if needed
Patience
Some residents seem to have these abilities naturally, for others they can be more difficult. All residents must learn and show the ability to use them. Often, when a resident just doesn’t seem to “get along” with patients, families, or even the nursing staff, deficiency in these skills is often the problem. Now we have common language for teaching and assessment.
1 Hobgood et al. AEM 2002;9:

25. Meaning Interpersonal and Communication Skills 1
Capable of creating a therapeutic relationship
Discuss condition with appropriate empathy
Demonstrate respect for cultural, ethnic, gender and age-related differences
It is the resident’s ability to do this that is at the heart of the patient-doctor relationship.
1 Hobgood et al. AEM 2002;9:

26. Meaning Interpersonal and Communication Skills 1
Use of comprehensible written and spoken language
Able to interact in an adaptable manner
When ready, advance to the next slide.
1 Hobgood et al. AEM 2002;9:

27. Meaning Interpersonal and Communication Skills 1
Able to negotiate and resolve conflict
Can function as an effective team member and leader
Capable of soliciting and implementing feedback
These skills can be very difficult for residents to achieve, indeed they can be difficult for attending physicians.
When residents are having difficulty, we as attendings need to be teachers, counselors, mentors, or even sounding boards. There’s not always a simple solution, but we have witnessed experienced attending physicians do this over the years, and know that they will continue to guide residents in attaining these skills. New attending physicians are often excellent at this as they have recently learned the skills, have empathy with the residents, and are able to very effectively guide and mentor residents.
1 Hobgood et al. AEM 2002;9:

28. Definition of Competency Professionalism 1
Arrives on time, ready to work
Maintains a proper appearance
Inoffensive dress and appropriate cleanliness
There are literally hundreds of articles defining professionalism. This definition is practical and meets our needs to explain the need for work ethic, appropriate appearance and behavior.
1 Larkin et al. AEM 2002;9:

29. Meaning Professionalism 1
Respectfully interacts with patients, family, colleagues and the health care team
Proper introduction and manner of speech
Advance to the next slide when you are ready.
1 Larkin et al. AEM 2002;9:

30. Meaning Professionalism 1
Demonstrates sensitivity to medical and emotional needs of patient
Appropriate use of humor/language
Maintains composure under stress
Advance to the next slide when you are ready.
1 Larkin et al. AEM 2002;9:

31. Meaning Professionalism 1
Willingly sees patients throughout shift
Conscientious transfer of care (sign-out)
Punctual completion of medical records
Equitable in recruitment and peer review
When residents get into trouble over issues not related to medical knowledge or patient evaluation, it is usually as a result of issues regarding professionalism. We now have language that residents are responsible to know. We have simple straightforward requirements they can and must meet.
1 Larkin et al. AEM 2002;9:

32. Meaning Professionalism 1
Demonstrates accountability, responsibility, and integrity !!
All of the components of professionalism are achievable, and residents must demonstrate that they are competent in performing them.
We can and should hold them to this standard.
1 Larkin et al. AEM 2002;9:

33. Definition of Competency Systems-Based Practice 1
Capacity to understand, access, and effectively utilize the resources of a given health care system to enable the provision of optimal emergency care
Systems-based practice is complex and growing more complex all the time. Many residents, especially in their first year of training, will find this very difficult and perhaps overwhelming. It is one of the reasons they are so slow in seeing patients. It is in this area that supervising physicians often need to help guide even experienced residents.
1 Dyne et al. AEM 2002;9:

34. Means Correctly Using Institution’s Resources
Computer system
Social services
Free clinics
Our clinics
Pharmacy
Radiology
Special Procedures
Vascular laboratory
Stroke team
Cardio Team One
Knowing and being able to effectively use resources may be one of the big differences between junior and senior residents and indeed between new and experienced attending physicians. It is often the most difficult part of going to a new institution.

35. Means Correctly Using External Resources 1
Ability to apply a working knowledge of different health care practice models and delivery systems to the treatment of an individual patient
Advance to the next slide when you are ready.
1 Dyne et al. AEM 2002;9:

36. Meaning HMOs PPOs Medicare Medicaid Prescriptions Dental Extended care
It is very important for residents to recognize the need to identify a patient’s primary care provider, HMO insurance, etc., so that patients can be referred appropriately to their primary physician or HMO insurance for follow-up or referrals when indicated.

37. Competency Objectives: Systems-Based Practice 1
Practice cost-effective health care and resource allocation that does not compromise quality care
Perhaps this is the Holy Grail for all doctors.
1 Dyne et al. AEM 2002;9:

38. Meaning Systems-Based Practice 1
Advocate for and facilitate patients’ advancement through the health care system
When patients write a letter of thank you to a particular doctor, it often mentions compassion, communication of information, or helping a patient or family navigate the health care system.
1 Dyne et al. AEM 2002;9:

39. Teaching Modeling of behavior Bedside teaching Discussion Feedback
Mentoring
Didactic instruction
Those were the competencies, now how do we teach them?
By the methods listed on this slide. Of these, modeling of behavior, bedside teaching with feedback and discussion, and mentoring have been shown to be the most important and effective. Didactic instruction is important, but may or may not change behavior. In fact, it often doesn’t.
Bedside teaching and modeling of behavior are of paramount importance. Mentoring may be how we enable residents to become our future leaders and find satisfaction in the career of emergency medicine. It may be how we teach them to balance their lives and remain healthy and effective. It may be one of the most important things we do.

40. Teaching Knowing the General Competencies
Making sure the residents’ practice and performance demonstrates attainment of the competencies
Teaching is dependent upon knowing the competencies, supervising the residents and helping them practice them, and finally assessing their progression in the ability to practice them.

41. Teaching
Helping residents to improve in performance of the competencies
Evaluating junior and senior residents progression in attaining ability to practice the competencies
Evaluating the graduating residents’ attainment of the competencies
When you evaluate/assess residents, you need to determine if they are progressing in attaining the competencies. If they are not, you need to state what they are not doing in specific language. That language is on these slides.
It is by informing the program and associate program directors of lack of progress that enables them to create individualized remediation programs for struggling residents. It is a very fine line between having the patience to allow residents the time they need to develop skills and knowing when progression in skills has stalled. It is here that the supervising clinical physicians observations are critical in helping the leadership of the residency programs make informed decisions about instituting support and remediation programs.
Finally, before graduation you need to tell us if they have or have not attained the ability to competently practice all of the behaviors required of them embodied within these competencies.

42. Methods of Assessment Global Ratings of Performance
Description:
Rater judges general categories of ability
Ratings completed retrospectively based on general impressions collected over time
Rating scales
Use
End of rotation/summary assessments
Numeric ratings plus comments
These are the methods used for assessing a resident’s performance. The global ratings are the written and verbal evaluations given during faculty meetings. It is most helpful if attending physicians use the New Innovations Residency Management software program to electronically evaluate resident performance for the following reasons:
You remember most about behavior if you provide feedback (give comments) in a timely manner (close to that behavior)
It documents what has occurred, both good and bad
It allows the program director to get an overall view of what is happening
Specific comments allow the resident to maintain good behaviors and improve those which need improvement.

43. Assessment Staff/faculty meeting Written documentation Improvement
Verbal discussion
Specific behaviors
Specific examples
Written documentation
Improvement
Correction for future improvement
There are several methods to provide residents with feedback on their clinical performance. When that feedback is provided, it should identify specific behaviors and contain specific examples of good or deficient performance. As faculty, we need to commit to this type of formative evaluation to provide residents with and understanding and the opportunity to improve their behavior. Without timely, specific examples, it is difficult for the residents to understand what they need to do to improve. It is not enough to just tell them that they need to improve. Providing them with specific instruction as to how they can improve will give them the opportunity to improve, and give you a measure against which to see if they have shown improvement.

44. Faculty Level of training
Behavior
Problem solving
As you evaluate or assess residents please remember their level of training. Is their knowledge appropriate for level of training or below what is demonstrated by their peers. Is their behavior consistent with the competencies or does it need improvement? Have they failed to improve despite your teaching and, if so, in what way?
Can they solve patient problems and, if not, in what way have they failed? In which competency have they not been proficient?

45. Faculty Level of training
Behavior
Manage time
Interact with patients
Courtesy
Leadership
In the listed behavior, what has not occurred?

46. Ultimately Are they progressing in mastering the competencies?
If not, what are the problems?
Upon graduation, have they demonstrated proficiency/competency in the Core Competencies?
Is improvement/progression occurring, or, if not, in what way has it stalled?
At the end, are they competent in the Core Competencies?

47. Summary Bulk of teaching by clinical attendings Modeling behavior
Verbal instruction
Discussion
This is the teaching you do and how you accomplish it. Without your teaching there is no program.

48. Assessment Bulk of assessment /evaluation by clinical attendings
You do the bulk of assessment/evaluation. Without your input there could be no evaluation program.

49. Evaluation of Resident Performance
On-line
New Innovations
Hard copy
Forms filled out and returned to the residency leadership team
These are the tools we use to report resident performance.

50. Summary Patient Care Medical Knowledge
Practice-Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-Based Practice
This is a listing of the General Competencies required of the residents.
The department, core faculty, and residency leadership would like to take this opportunity to thank you for all of the teaching you do, the time and care you take with the residents, and acknowledge that you are the foundation of the training program. Without you there is no program.
Also, please take time to fill out the evaluation of this slide sound sequence.
Thank you.