Carlos Roberto Jaén MD, PhD
According to Merriam Webster’s dictionary, tipping point is “the critical point in a situation, process, or system beyond which a significant and often unstoppable effect or change takes place.” It’s not when the change is fully apparent, it is when it starts irreversibly. As the Affordable Care Act and 2014 loom in the horizon, some of our academic colleagues in the ROAD specialties are describing the local professional scene as one of “suffering” for their colleagues (“They’re losing their shirts”), probably an exaggeration but nevertheless a change. Many of their graduates, after years of “investment” in their training, will be disappointed.
We must remain steely in our resolve to build residencies and undergraduate programs that teach the fundamentals of the new order: team communication, team building, population health, whole person/whole population care—at whatever cost is necessary and possible. We must do the right thing for our patients and the populations we serve. Yes, we must do this in the middle of a rigged system that undervalues, despite all the rhetoric, what we do in primary care. We must educate our colleagues to the reality that primary care is so much more than wRVUs and “feeder” programs. They must lean that primary care is “taking care of folks,” over time, with commitment. It is about populations and lives we care for, not about more procedures and visits only. We are not ambulatory care like radiology and/or ambulatory surgery are ambulatory care.
Primary care is about embracing complexity with gusto. Yes, we are the experts in complexity because we deal with complexity in context. We cannot afford to wait for the payment fix to be in place to act. By then it will be too late. We must cobble our road with the fundamentals so that when 25-year-old medical students wake up, and they will wake up, they will have a road that leads them to take over for us before our rocking chairs arrive. We must keep in mind what our Advanced Primary Care Team recently discovered, the currency of primary care—of family medicine—is “Atención y respeto” (attention and respect). That is what our patients deserve, that is what our communities expect, and that is the foundation on which our next generation will build the next iteration of what we offer today.
A hopeful fool in San Antonio,
Sam Cullison, MD
Anyone working in family medicine graduate medical education knows that the bar is being raised by the ACGME, as well as by society in general, to demonstrate that our residency graduates are truly prepared to show “sufficient competence to enter practice without direct supervision.” This is not a new standard for graduation, but the rigor with which we must prove residents’ ability is getting tougher.
Some of us (like me) were in the field when Dr David Leach first announced the six competencies in the late 1990s. We were warned that requirements would be progressively increased and that proving competence would require more than verifying time and clinical exposure, with faculty sitting around a table venturing abstract opinions based on recall and the group dynamics of the moment.
However, there is good news in all of this. We are being challenged to prove we know what we are talking about when we say a resident is ready to graduate. Being challenged to defend one’s beliefs is nearly always a good experience, since it requires reassessing assumptions and asking ourselves why we believe what we assert. And to build on that good news—assessing competency is not as tough to do as one might think. I am now a year into chairmanship of the Residency Competency Measurement Task Force, chartered by the Council of Academic Family Medicine and administrated by the Society of Teachers of Family Medicine. I came to the role with a lot of leadership experience but not much competency in competency measurement and tools. Fortunately, I have learned a lot from the other task force members and read tons of books and articles. I have decided that this can be done.
So, what is it going to take?
We have created a web-based Resident Competency Assessment Toolkit. I think it does a good job of walking faculty and directors through the tools available for competency assessment and how to use them.
A couple of general observations:
- The tools can be simple to use.
- One tool can be used to measure more than one competency. For example, I can use direct observation, (watching a resident care for a patient), to analyze medical knowledge, patient care, communication, and professionalism in one sitting.
- You can decide how many tools you want to use to measure any given competency.
- Multiple faculty watching a single resident provide care to different patients over different times accumulates a body of information on competency that is both valid and reliable, especially if forms are used to record findings and faculty have been trained together to create common standards.
- Feedback is valuable when received from sources outside the faculty: staff, patients, peers, and students.
- Learners love feedback, and more of it more often “normalizes” it and takes away the stress.
- There is no perfect form; do not spend time searching for “the holy grail” of perfect forms. Find one already in use elsewhere, modify as you must, and then start using it—frequently and by many assessors.
- Faculty need to work together to reach common definitions of competency. Otherwise, faculty assessing the same clinical events will reach very different conclusions.
GO FOR IT!!