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SPECIAL ARTICLES

Competency-based Education in Anesthesiology
History and Challenges
Thomas J. Ebert, M.D., Ph.D., Chris A. Fox, Ph.D.

ABSTRACT

The Accreditation Council for Graduate Medical Education is transitioning to a competency-based system with milestones
to measure progress and define success of residents. The confines of the time-based residency will be relaxed. Curriculum
must be redesigned and assessments will need to be precise and in-depth. Core anesthesiology faculty will be identified and
will be the “trained observers” of the residents’ progress. There will be logistic challenges requiring creative management
by program directors. There may be residents who achieve “expert” status earlier than the required 36 months of clinical
anesthesia education, whereas others may struggle to achieve acceptable status and will require additional education time.
Faculty must accept both extremes without judgment. Innovative new educational opportunities will need to be created for
fast learners. Finally, it will be important that residents embrace this change. This will require programs to clearly define the
specific aims and measurement endpoints for advancement and success. (Anesthesiology 2014; 120:24-31)

T HE Accreditation Council for Graduate Medical Edu-
cation (ACGME) is transitioning from a time-based to
a competency-based education system. It is a learner-centered
units of behavior is a reductionist approach when a more
holistic approach to resident assessment may be sufficient.2
Qualities that distinguish outstanding providers, for example,
approach that emphasizes achieving specific outcomes called critical decision making, multitasking, situational awareness,
milestones. The ACGME milestone project was designed to empathy, leadership, and resource management, may not be
allow each Graduate Medical Education program to iden- adequately developed and assessed in the milestone model.
tify the behaviors and attributes that constitute the essential Since this conversation first began, there has been debate
competencies for their specialty.1 A key assumption for our over the “what, why, and how” of a competency-based,
specialty is that the skill set and knowledge required to pro- postgraduate education program for anesthesiology that
vide safe and effective anesthesia care can be broken down incorporates milestones into the learning process.3–6 As Yogi
into subsets called milestones. The milestones are subsets of Berra once said, “If you don’t know where you’re going, you
the six general competencies, and each must be easily identi- ain’t gonna get there.” Educators will debate the costs and
fiable and measureable. Education leaders in anesthesiology benefits of a changed construct for education, and program
have identified 25 milestones and have framed each mile- directors will lament the challenges with curriculum design
stone in the context of a developmental continuum from and equitable and consistent assessment. Residents will need
novice to expert. It is expected that progression through the to know precisely how they are progressing and what it takes
milestones will lead to overall proficiency in the specialty.* to achieve the expert level of each milestone. This mono-
The rate of achieving competency now becomes individu- graph reviews the historical basis for the time-based and
alized for each resident. The traditional assumption that all competency-based education programs and presents some of
residents will progress similarly at developing proficiency in the special challenges resulting from the upcoming paradigm
the specialty no longer exists. This concept will create special shift to milestones in anesthesiology training programs.
challenges for education programs where the acquisition of
the competencies may no longer be defined simply by a fixed Historical Perspectives on Medical
time in the program. Rather, length of education should be Education
removed from the equation in favor of a visible demonstra- Before the initiation of a time-based residency program,
tion of knowledge, skills, and behavior attainment. Some will young, aspiring, physician trainees learned their specialty
argue that becoming a competent anesthesiologist is more as apprentices. As might be expected, there was substantial
than the sum of the individual milestones. Reducing complex variability with patient contact and case exposure that led to
behaviors required of an anesthesiologist into small observable a highly inconsistent development of diagnostic and surgical

This article is featured in “This Month in Anesthesiology,” page 1A.
Submitted for publication May 1, 2013. Accepted for publication September 30, 2013. From the Department of Anesthesiology (T.J.E.),
Medical College of Wisconsin, Milwaukee, Wisconsin, and Zablocki VA Medical Center, Milwaukee, Wisconsin; and the Department of Anes-
thesiology (C.A.F.), Medical College of Wisconsin.
* ACGME. Available at: http://www.acgme-nas.org/milestones. Accessed September 11, 2013.
Copyright © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2014; 120:24–31

Anesthesiology, V 120 • No 1 24 January 2014

Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/journals/jasa/930986/ on 03/04/2018

William The Millis report. report by Abraham Flexner9 (1866–1959. A care provided by seasoned practitioners. During this early developmental period in medical 1963.11 Although the founding Dean at Hopkins. entitled “The Graduate Education of Phy- Welch. the goal of the schools was frequently financial decade. Residency of residency education for each subspecialty. with the formation of the ACGME in through residency. helped establish the requirement of a college degree wages. Each training the completion point of medical education with only a few hospital was allocated payments based on the defined length choosing to proceed to a specialized residency. German. Founder of the Institute for Advanced Study in Prince. based on the elderly patient census in the hospital). Flexner had emphasized the need for a strong scientific basis M. M. These occurred with the Flexner training should not extend program length. internship was most often needed to assist in the care of these patients. cation program were described at Johns Hopkins. in the United States and Canada (aka the Flexner Report) in The Millis report also showed great foresight in dis- 1910.D. Fox Downloaded From: http://anesthesiology.” education programs and their emphasis on the scientific Nearly simultaneous with publication of the Millis report. J.” was published in 1966. Flexner was a brilliant educator and a non-physician cussing the corporate responsibility of the hospital system who had few prejudices and preconceptions regarding medi. the fundamental elements of a time-based edu. 15 yr after the recommendations from the Millis mittee (RRC) for the specialty. Refinement in the time-based model urged that new scientific advances and knowledge be part for residency education occurred along the way with four of intern and resident education. (1850–1934. with the passage of the Medicare Bill of advances in knowledge needed to be integrated across the 1965 and the nearly simultaneous publication of the Mil. Founder Johns to medical education. scholar at the Carnegie Foundation for the Advancement The report recommended a newly formed “commission on of Teaching. Rather. The first residency was established with new scientific findings were not being incorporated into the a predefined program length and structured educational practice of licensed providers. There was thus integrated into the established model of a fixed- was no central authority that governed approval of residency time in a single residency. For anesthesiology residency programs. that is. entitled Medical Education established base.7 Medical education transformed to direct patient limited.D. Ebert and C. entire continuum of medical education. Ohio. He visited 155 medical schools in the United graduate medical education specifically for planning. leading to fragmentation. 120:24-31 25 T. with funding from a new tax imposed on America. allowing residency education to focus on building from an ton) to the Carnegie Foundation. then in its seventh education. periodically reviewing standards of graduate medi- His report and recommendations were influenced by his cal education.D. tor. They explosion of scientific research findings had led to “complex- and colleagues established a science-based foundation for ity and fragmentation” in medical education. medical education. to support education over service. 1988) to do a second external review on medical education. The support programs were more about service than education. and for reviewing and approving the training previous knowledge of university-based. SPECIAL ARTICLES skills. and support to teaching hospitals for gradu- the 4-yr medical education (2 yr in the “laboratory” and 2 yr ate medical education. the Millis report recognized that the Hopkins Hospital).pubs. Specifically. commissioned John S. graduate medical education took a large organizational Anesthesiology 2014. In report. and mentions the need cal education.10 The Flexner Report sounded the the Medicare Bill of 1965 established the federally managed death knell for the for-profit proprietary medical schools in Medicare program. Founder sicians: A Report of the Citizens Commission on Graduate Johns Hopkins Hospital). The Millis report period of supervised practice was to follow completion pointed out that internships were fragmented by rotations in of medical school.7 at each hospital and the number of postgraduate trainees In the early to mid-1900s. programs.ashx?url=/data/journals/jasa/930986/ on 03/04/2018 . as the first Chief of Medicine. basis of medical practice. Case Western Reserve University in Cleveland. too often emphasizing menial model was conceptually challenged. Ph.8 Over the next century. Medicare provided health insurance for people aged for admission into medical school. he became a research for “translational” teaching and research across specialties.asahq. American Educa. dations from the Millis report aimed at reducing fragmen- tion in 2002. After 19 yr of teaching. and formed the basis of 65 and older. Professor of Pathology. a Yale graduate who served as Medical Education. other than the specific Residency Review Com. Although the Millis report time reasonably well. A. incoming CA-1s now begin with a more consistent skill set. recruited William Osler. 1849–1919 (Professor of Medicine. 1981.. from medical school lis report in 1966. Millis. 1903– In 1889. life-long learning was content. internship became well One of the first improvements to the time-based model delineated with rotation requirements in fairly narrow and established at Johns Hopkins followed a comprehensive applicable areas. dinating. coor- States and Canada to complete his comprehensive survey. the American Medical Association. tation in education. the Hopkins many different subspecialties. Furthermore. these Report of 1910. (President of gain rather than high-quality physician education. incorporating them into periods of distinct change.org/pdfaccess. but stood the test of tasks of little educational value. In 1981. medical institutions. leading to inadequacies in the quality of medical experience with escalating patient care responsibilities. and most recently with the ACGME’s adoption of The RRC for anesthesiology incorporated recommen- the six general competencies for graduate medical educa.

Professor of Applied Mathematics. Chief with “knows how. There is a renewed emphasis on the central theme of hours led to a concern that programs would not be able to progressing through residency with the attainment of ever- train truly competent physician consultants. Miller’s (George Armitage many “lifestyle” rules designed to improve the educational Miller. competency-based education ior. possessed skills adaptable to diverse and ever-changing is an outgrowth of the three learning domains described by healthcare systems. the subjective nature of assessment risk took precedence over affording trainees opportunities prevalent in traditional education programs is replaced with for critical decision making. Fox Downloaded From: http://anesthesiology. At the based education relies on the notion that with specific. For example. 1920–2012. exhibited improved professional behav. attempts be extended. the ACGME challenged residency programs or the skills and knowledge they possess (learned and/or to develop a broader. that is. same time.. more diverse physician for the work. the additional time was not used level to advanced levels is an outgrowth of the Dreyfus (Stu- to “sleep and mitigate fatigue”—the desired goal of duty art E. Milestones within Competency-based ing from media scrutiny of healthcare delivery. and the psychomotor domain reflecting manual Residents needed to demonstrate knowledge and skills in skills. or competence in medical education. the affec- the ACGME within a time-limited training program. Professor of Psychology. emotions. A. The goal was to develop residents who and clinical and behavioral skills. cian by breaking down the sum (a competent. and embraced life-long learning. Does Time Matter? Competency-based Education step forward with the establishment of the ACGME.D. the model of The ever-growing educational and service needs were. the ACGME instituted tion and synthesis of knowledge. achievable objectives for residents to remain productive and generate revenue. behavior.asahq. These milestones are designed to measure an learning and improvement were added to medical knowledge individual’s competency in the areas of acquired knowledge and patient care skills. They proposed that the standard assessment of resident a subset of knowledge and skills required to successfully per- performance—patient care skills and medical knowledge— form the job. Ph. able.. University of California-Berkeley) model of skill acquisi- † Nasca TJ: An Open Letter to the GME Community.pdf. then. 2013. sional authenticity at or beyond completion of residency. the 2005 imple. easy to measure and evaluate. The hour restrictions.14 Here. then “shows how” and “does” to achieve profes- Medical Education Community. traditional time-in-training model because it is defined by First and foremost.A.org/acgmeweb/Portals/0/PDFs/nascalettercommunity tion.15 The Dreyfus model described a progression of skill 10_28_09. Competency-based education. It follows work hours..D.” much like a first-year clinical anesthesia Executive Officer. mentation of duty hour restrictions had unintended con. 2002. Ph. with continued and growing ACGME provided oversight of residency programs and the public concern for the impact of resident fatigue on patient accreditation process for postgraduate medical education safety. And because faculty had to discreet. Ph. forcing additional restructur- safeguards were in place that protected them from receiving ing of patient care services and education. tive domain comprising attitude. The accreditation process assured the public that lines was established in 2011. Prince- environment for residents. Competencies of systems-based practice.C. parts communication and interpersonal skills.acgme. Bloom (Benjamin S. In its fundamental form. development from novice. transparent. The model of pro- hour restrictions had a positive impact on residents’ percep.† it seemed the imple.. Accessed September 11. developed in 1990. competency-based educa- action (outcomes). Bloom. and grams were charged with a new focus on learner outcomes. it seemed that an institution’s need to mitigate measurable outcomes. and practice-based (milestones). Pro. Dreyfus. M.D. independent cies. case reports. Although duty increasing levels of knowledge and skill. Traditionally. there was shown to be little correlation outcomes rather than number of encounters. Education and commentary in scientific publications.13 These are the cogni- system for graduate medical education were established by tive domain encompassing intellectual capability. professionalism. NJ) pyramid. the restricted duty meet. Competency- between restricted duty hours and patient outcomes. reigned in by predefined daily and monthly to the medical student/intern level of development.” which will typically apply the first time. J. Nonetheless. In response to The terms competence and competency are not interchange- demands for accountability for graduate medical education. gressive development of the anesthesia resident from entry tion of work/life balance. ACGME) 2009 Letter to the Graduate resident. 1913–1999.P. for competence begins with “knows. whereas competency (at a job) indicates a mastery of force. 120:24-31 26 T. Competency-based residency education differs from the sequences for both residency education and patient care. In addition. American The early elements of a competency-based educational Educational Psychologist) in 1956. competence refers to a person’s ability on July 1. As outlined in Nasca’s (M. They implemented requirements for trainees to to define the requirements to become a competent physi- meet criteria in six areas termed the core or general competen.. describes a framework mentation of duty hour rules for residents and fellows led for evaluating the progression of clinical development and/ to substantial changes in fixed-length residency programs. a second iteration of the ACGME duty hour guide- programs. communicated better.12 There began an era of increasing public awareness of medical errors emanat. Available at: www.pubs. rather than simply the acquisition of tion looks beyond acquisition of knowledge to the applica- knowledge and skills. physician) into smaller. unsupervised care from resident physicians. the person who essentially Anesthesiology 2014. As with Bloom’s taxonomy. innate).ashx?url=/data/journals/jasa/930986/ on 03/04/2018 .org/pdfaccess. ton. feelings.D. Ebert and C.

an outcomes-based model requires flexibility in curriculum Although there is no clear evidence in medicine that qual- development and assessment methods to adequately meet ity and patient safety will improve with a milestone-based the needs of individualized learning paths. Removing time from the equation opens the door to expanded experiential learning in the operating rooms.org/pdfaccess. from novice to advanced learner. tion in terms of its intended goals and outcomes. and the frequency of evaluations all have the argument that begs for improved and expanded experien- potential to lead to inherently stronger global assessments. NC) argued that the segmentation and linear assumption of Outcome-based education was defined by Spady (Wil. Without too much effort. The current. learning assumed in outcomes-based education did not real- liam [Bill] G. proficient. and documenting instruc. rather than writ. driven by their growing interest in quality and safety. is mostly have historically designed their curriculum around a time. and ultrasound-guided. Years time will be needed to establish a highly competent resident. left ventricular assist devices. developing. access the rules relevant to the task. it seems intuitive that it might.17 tial learning. has reduced learn- ers’ time in the classroom and the hospital. In the intensive care unit. Proficiency is estab. Some will assume that this means more Miller’s Pyramid of Assessment of Medical Trainees. coincident with duty-hour restrictions. Challenges with decisions. That is why. and more.asahq. Consider the time needed to develop skills in transesophageal echocar- diography. defined by finite steps or time.. and simulation labora- Fig. The robustness of education program. evaluating what students have not learned. A. and the possibility of unintended consequences. the quantity and quality of data the viewpoint of the learner. in anesthesiology training. Figure 1 is a new model of professional develop. it is important to be cognizant of the possible lished with the ability to prioritize and use intuition to guide limitations of the outcomes-based model. unmet. J. we can list a number of advances in the field of anesthesiology that arguably require more time for skill development and mastery. and complex procedures in the pain clinic including radio-frequency ablations. the “why change” becomes an being collected. SPECIAL ARTICLES is following rules without context and no sense of respon. time-based model of education. as we transition to competency-based and develop decisions about the task. ability for medical education. A pictorial representation of professional development tory. that in the finally expert.pubs.”16 This means the educator must develop the curriculum for the out.ashx?url=/data/journals/jasa/930986/ on 03/04/2018 . encouraged by our 24-h news cycle. International Center on istically reflect the natural learning process. Residents become better equipped to provide complex. Director. another need goes to organize principles. From individual assessment tools. Competence comes with the learner’s ability quest to meet one need of the trainee. 120:24-31 27 T. of training to achieve expert competency are not finite and The more accurate interpretation would be that education can extend into professional practice. Greenville. East Carolina University. Spady. stimulator implants. Ebert and C. Speed of development of individual residents is depicted as a continuum. of course. anesthesia is being called on with increasing fre- quency to manage complex patients including a growing volume of patients with multiorgan transplant. programs will need a robustly defined and developed way stones now serve as the assessment metric to determine the to advance the successful resident along the learning contin- development of the resident during the continuum. Progression through residency education is not tightly comes within those broader domains. competent. there is always sibility. This figure extends the classic perioperative care. or from routine cases Anesthesiology 2014. Switching to a curriculum that supports avoidance of adverse outcomes (both financial and personal). but with progression that is Professor of Education. As with every challenging new initiative. and in-training format. uum. education. clinics. neurolytic blocks. Here progression is of creating curriculum that matches and enhances outcomes displayed with learner development across a continuum of and the struggle to accurately measure higher-order out- time. to advanced beginner. a big challenge to training programs that demand. outcomes-based education models lie in both the difficulty ment in a competency-based system. demanding knowledge of newer ventilation modes. The mile. Fox Downloaded From: http://anesthesiology. The “why” may be as simple as society demands account- ing competency-based objectives for an existing curriculum.D. Eagle. Societal and governmental This is. CO) as a “way of that the focus on measurable objectives was often flawed by designing. expected to overlap training years and extend into practice. WHY Change? comes they want residents to demonstrate. yet scientific advancements have expanded the breadth of knowledge and skills required of a competent physician.18 McKernan (Ph. intensive care units. ultrasound imaging for nerve blocks and cath- eter placement. delivering.19 He also stated Outcome-Based Restructuring. 1.

and faculty interactions with the learner. Some each program. Supervisors’ evaluations were derived from their Competency-based medical education provides new direct observations of residents’ performance with “live” challenges to teaching faculty to become “trained observ- patient care. if a resident education is effective for developing the complex. a learner’s case expe- on assessment in simulation. right heart failure. the RRC for anesthesiology hemodynamics in patients with complex valve abnormalities.” Evaluation of learner success within the framework of performance. In a study involving 301 residents from four tion. J. acquires sufficient knowledge to pass the In-Training Exam.25 based model in evaluation of surgical skills. simulated experiences were evaluated against super. roughly two thirds of residents were considered milestones is far more challenging when compared with tra- “competent” at the end of their education program. but are never asked to settings. the finite number of experiences the RRC considered neces- nity did not present itself in the clinical setting. ulty acceptance. Residents can be asked to extend defined.ashx?url=/data/journals/jasa/930986/ on 03/04/2018 . Oth- (outcomes) were not dependent upon a specific teaching ers will need additional core training and risk the stigma of methodology and delivery system to be successful. out sessions. ditional assessment methods. This transition will have challenges including: pain. one can debate whether competency-based ogy resident education can occur. residents will fulfill requirements early and hope to head off cal education have concluded that the educational domains to practice or enter into advanced educational settings.22 These guidelines provided a basic structure that could be individualized to Quite simply. without necessarily adding time to effective as another using a completely different one. including pterional craniotomy and exposure of the validated assessment tools. medical school that used one teaching approach was equally Accelerated learners who rotate off a service or out of training Anesthesiology 2014. for example. flexibility has to be built into programs. education time if their skills and knowledge are not up to visors’ assessments of residents’ “live” performances in clinical the standards set by the program. Ebert and C. addition. comparable. The Society of Education opposed to 33–36 months in the time-based model. management of resident education programs. high-fidelity sary for each resident to acquire the knowledge and skills simulation could fill the gap. time frame. Other outcome-based frameworks for medi. In 2011. require fluidity in the resident training program. lated into a summary evaluation. Does Time Matter? Competency-based Education to the more challenging.pubs. in figure 1. A. A milestones-based model of residency education will pean Board and Section of Anaesthesiology has imple. However. on-and-off pump procedures.8 in Anesthesia at their June 2013 annual meeting specifi- Competency-based educational models have already cally targeted these challenges with work groups and break- been implemented outside the United States. If the opportu. noteworthy challenges and barriers came from fac- For example. and/or an different medical schools. The European Education and Training Group of the Euro. all extrapo- Neurosurgery Department has been using a competency. They found that Two important steps to implementation of the mile- residents were able to master skills in the most complex pro. Instead. and significant These standards defined the educational curriculum and arrhythmias would be carefully structured. higher. left ventricular Rather than guide us in the educational construct of our assist devices. operating room staffing models have limited flexibility. order skills required to practice as a professional. On the basis of simply observing the clinical ers. pulmonary hypertension. The same would need to be developed for all learning to consider a resident “competent” at the end of the 3-yr areas within anesthesiology. followed implement change. We will be calling upon our optic chiasm. problems.asahq. This type of competency-based to meet American Board of Anesthesiology requirements teaching and learning could assure that a resident from any for certification. own outcome-based educational model.23 In the training program. aortic balloon pumps. extend education time because of failure to have had a chal- dent’s performance with 50 simulated patient-management lenging cardiac case. Johns Hopkins’ riences.org/pdfaccess. right heart failure. to establish competence in cardiac anesthe. they released a new edi- 1. Competency-based evaluations consisted of the resi.24 by defined experiences in the clinical setting. The resident’s progression of skills and knowledge of transesophageal HOW: Implementation Challenges echocardiography. as shown mented competency-based curricula in anesthesiology. has defined standard requirements for these programs. and mean. cation programs designed curriculum and exam thresholds sia. stones have been left poorly defined: curricular design and cedures. Unpredictable time spent on a given service and in over- tion of postgraduate education guidelines that define their all education. but has never port from a wealth of educational literature documenting its had to deal with a complex cardiopulmonary bypass separa- effectiveness. 120:24-31 28 T. Fox Downloaded From: http://anesthesiology. For example. pulmonary hypertension. and intensive care. Because residency program structure and program would have a consistent. meets his/her numbers in cardiac anesthesia.21 Since 1994. at 18 months into their educational program as societies to help with these steps. a extended training when competing for fellowships or jobs. Those methods had relied on less than 2% of residents were considered competent based performance on multiple choice exams. A flaw in the current structure of anesthesiol- Although.20 it has sup. competency-based assessments in intraaortic balloon pump. and development of adequate resources to sia could mean standardized classroom teaching. edu- ingful experience in the specialized field of cardiac anesthe.

context specific.26 Currently. SPECIAL ARTICLES (currently not defined in the American Board of Anesthesi. their institution. or patient safety and quality improvement. The RRC for anesthesiology has previously defined course. or to manage their ident who meets case number criteria on subspecialty rotations own cases. and attitudes to progress to the next level. based education program. This means programs must have sistency in implementing milestone-based education could clear goals and objectives so that we can better measure lead to unfair competition as medical students burdened with achievement. Fox Downloaded From: http://anesthesiology. early switched to competency-based education. Experiential learning theory would suggest that a res.asahq.ashx?url=/data/journals/jasa/930986/ on 03/04/2018 . Thus. and the field of dents where they are in attaining the necessary knowledge. When Brown University School of Medicine skills. for example. they found their achievement of a set of milestones could or should come faculty were initially skeptical. to a competency-based. These interns felt the learning outcomes were very process begins over a year before completion of residency. improvement.” Furthermore. lose rigidly defined Medicare-Graduate Medical Education such as an earlier opportunity to moonlight.27 faculty “buy-in” and acceptance that the milestones are not isolated and superficial add-ons to training requirements. their trainees. For example.pubs. Resident acceptance the faculty are both the deliverers of content and the assessors We must be careful not to disincentivize residents. as opposed Successful outcome-based education requires significant to just altering graduate medical education programs. taking on a quality ology guidelines) will increase demand for more physician improvement project in the subspecialty. Depart- patient care due to advanced educational opportunities could ments could offer financial incentives for accelerated success. As 3. Ebert and C. would offer advanced training in a subspecialty. Residents will need to to complete their formal education early in order to keep them know precisely how they are advancing in the milestone- competitive in the resident recruitment process? Lack of con. This from a pathway to finish in a shortened time frame. Rather. or perhaps departments and institutions. books. A. bility to clinical practice. will education programs be compelled to allow rapid learners Caution is warranted however. compromising residency complement numbers or American Board of Anesthesiology/RRC training requirements. or involve themselves in teaching in the classroom would further develop skills and imprint learning by repeating or simulation laboratory. or payment funding support and add to the department’s cost of resident for transesophageal echocardiography certification. In a recent study from Denmark. This could include advanced experiences that a ment) and that the milestones might have limited applica- cardiac fellow might typically get. They had welcomed the transition hop- Would fellowship programs want to know about the rate at ing for better supervision and feedback but did not sense an which the candidate was meeting milestones and their antic. Faculty acceptance sequence” if residency education was truly fluid? This raises a point for changing medical education at all levels. Another option achieved competency in a specific milestone might not benefit might be to create mini-fellowships for early achievers. Because safe practice experience in an environment of “lightened” faculty supervi- builds on repetitions and routines. with the attitude of “if it ain’t with rewards. in educa- they might enter into an advanced or expert education process tion. developing inno- extenders and may add a financial burden on anesthesiology vative teaching models using electronic media. 120:24-31 29 T. Dangers of fluidity these options would provide a strong incentive for residents When competency-based residency education is fully adopted.29 Faculty may feel that with milestones in cardiac anesthesia should open up other the complex tasks required for an anesthesiologist cannot opportunities while on rotation for advanced education or be broken down into simple behaviors (necessary for assess- unique cases. Residents would continue to gain the same or similar process over and over. this mined. anesthesiology. training with the cardiology department. while not and be “teachers” to their colleagues.28 ipated date of graduation? Could they accept fellows “off- 4. Any of 2. 12-month curriculum from an Offering a fluid education program could also negatively 18-month. J. be assigned to mentor junior residents. learners who have already sion that comes with acquired competence. to achieve milestones in a timely manner. a review education. a minimum time on subspecialty rotations and in residency Perhaps the incentive to succeed is an early transition education. cial to them. it is essential that they support the notion milestones provide a developmental road map for achieving that the adoption of competency-based education is benefi- the general competencies and should clearly inform resi. This may prove to be too limiting to the milestones from resident to resident instructor. The of competency. transesopha. The foundation of faculty buy-in geal echocardiography or transthoracic echocardiography may be the tangible demonstration that what they will do Anesthesiology 2014.org/pdfaccess. traditional. ibility in rotations. They expressed concern about lack of flex- with most positions filled well in advance of graduation. The “fast learner” could concept. faculty worried that a cur- the next level on the developmental road map. or board examination fees. the intern debt might chose a program with the greatest potential for a perspectives on the gains and losses when transitioning “fast track” to advanced training and/or junior faculty wages. process-based program were deter- impact the fellowship application process. Perhaps the reward is as simple as advancing to broke don’t fix it. but there may riculum that valued competency and skills would leave room be ways to add other incentives. Residents not providing direct receiving special recognition within the program. rapid success for huge deficits in knowledge base.

J. successful residents who meet the milestones early. When one is in possession of all the individual puzzle pieces will require a well-organized plan that includes faculty and (milestones). quately judge whether or not the skill has been internalized. rather. Department of Anesthesiology. Iobst (William F. resident).e. there remains a significant effort required learner acceptance as well as strong administrative support. M.32 Medical College of Wisconsin. whether or not the resident can perform a specific skill and incentivizing. Furthermore. and other specialists. better resident’s knowledge. but remains lack. to exceed the standard. ditional.. transition to the new model.35 to correctly place all the pieces together to complete the There will be a significant investment of time to train fac- puzzle—it is only then that one can view the picture (the ulty to be skilled assessors of residents’ knowledge and skills. Hodges et al. Wisconsin.ashx?url=/data/journals/jasa/930986/ on 03/04/2018 . Toni D. There are other unwanted consequences of breaking competency-based education. Because the focus is on We have summarized other challenges with funding.asahq. case numbers.34 ment when using a competency-based education model. M. must not forget the residents in the equation.. tors of expertise. Milwaukee. discriminate between high and low trainee performance. both in the form of tangible test scores. technicians. trustworthiness) of a resident Thus. faculty must be The challenge is in finding the appropriate assessment tools made aware that the decision about whether a resident is to measure the specific outcome. ideas for a framework to meet the challenges of those most it can be difficult to measure their true global performance. and can be a focus of many types program director to make that decision. learner. The change to a competency-based edu. We have also offered not whether or not they use it correctly and appropriately. when improved learner outcomes can be demonstrated. ways to participate in academics.31 suggested that checklists (Objec. in the absence of some sort of global rating metric. tance of the new paradigm and this will only be achieved able. time-based education? Residents may prefer gen- which could potentially discourage residents from striving eralized objectives (meet rotation objectives. B. meeting milestones early. Ander- mance metric such as. Medical College this task independently?” could be a more reliable way to of Wisconsin. Does Time Matter? Competency-based Education going forward is better than what they have been doing. Barney. Ebert and C. Assessment Challenges with Competency.org/pdfaccess.30 sition will likely include intermediate hybrid frameworks Competency-based education is particularly suited to containing time and process components as well as specific the assessment of discrete procedural skills. and truthfulness.S.. rather than focusing on the amount of time it took Physician. For example.. competency-based outcomes. insight into and patient outcomes. including nurses.S. other skills.D. judgment and/or decision making.. discernment (i. However. We multifaceted competency of that resident. and in fact. Uhrich. “The tran- to achieve one or more milestones. such as life-long learning. and In-Training Exam thresholds) to a more individualized.S. Assessing the competence (i. because of its focus on indi. and Jill A. and an overall betterment of the daily awareness of limits). complete. skill. Allentown.33 clinical life.pubs. Outcome-based education is advantageous to time-based residency to a competency-based residency will learners because it promotes individual achievements by the be a noteworthy challenge. faculty buy-in will require measurable and deliverable for independent clinical work is a construct based on that outcomes. “high def ” picture that defines the true. require a longer-term based Training relationship between the evaluator and the trainee to ade- There are a number of opportunities for meaningful assess. for example.”27 There must be flexibility intubation or line placement. of multisource assessments by different types of providers. specific skills that are actually demonstrated in person. PA) has postulated that. Fox Downloaded From: http://anesthesiology. Having a global perfor- The authors thank the assistance of Christopher J. Iobst. 120:24-31 30 T. Our assessment tools must not only measure the There will be a daunting challenge to gain faculty accep- individual pieces but must aggregate them into a recogniz. Robust tools for ing in the assessment of the nontechnical skills such as assessment will need to be developed. sures for fairness and to garner the potential rewards from tive Structured Clinical Examinations) are poor discrimina.. A. reflecting the new core values of the department Outcome-based curriculum relies on trained observers and/or institution.e. the tion skills can be assessed “on-the-job” or via the completion milestones have provided a framework and tools to help the of a scholarly presentation. regardless of how it is done. (faculty) and performance-based assessment measures of indi- cational process may afford faculty opportunities for novel vidual. The Another way to consider this is the jigsaw puzzle analogy. for resident variations in skill achievement. and adaptability built into education programs to account vidual and attainable patient care skills. communica- ready for independent practice has not changed. experienced physicians may score even Acknowledgments lower on checklists than trainees. conscientiousness.28 It is certain that they will down the key elements in resident education to a series of demand consistency and reliability in new assessment mea- checklists. “Do I trust this trainee to perform son. M. the greatest being that evaluations are based on a detailed Making the Transition rubric (the milestones) that is available to both the trainer The changes that need to be made in order to go from a and trainee. Anesthesiology 2014. Finally. What will be the assessment must not focus on the minimum level of their perspectives on competency-based training versus tra- acceptable performance (performing at an expected level). and avoiding stigma.

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