How the APA Educational Guidelines for Residency Training in General Pediatrics
is Responding to the ACGME Outcomes Project

The Accreditation Council for Graduate Medical Education (ACGME), in conjunction with the American Board of Medical Specialties, has embarked on a project to move all residency and fellowship programs toward a new, competency-based educational model. What is the reason for this paradigm shift? The mission of the ACGME is to ensure high quality graduate medical education, and it is accountable to the general public, who ultimately provide much of the financial support for medical education. The move toward competency-based education is an effort by the ACGME to enhance accountability in medical training. The Council must prove to policymakers and citizens, using reliable performance outcomes data, that health care and training costs are not inflated and that patient safety is not compromised by inadequately trained physicians.

Although the medical profession has in the past been protected from this kind of external critical scrutiny, the entrance of health care into the world of business has led to the application of business standards to the profession. While clinical educators may lament this change, most can at least recognize some common ground with government policymakers. We share the desire to graduate physicians from our educational programs who are well trained and fully prepared for the challenges of medical practice.

The ACGME, after investing significant time and energy in review of the medical literature and discussion with experts, decided to address the demand for better accountability by altering its accreditation standards and approach. While in the past the accreditation requirements emphasized the structure and process of training programs (so many weeks of specific kinds of training, so many patient encounters per day, etc.), the new requirements emphasize the outcomes of training. In the future, program graduates must be certified by the program director as having met six broad professional competencies that cut across the medical disciplines and specialties involved in graduate medical education. These competencies are: 1) patient care, 2) medical knowledge, 3) practice-based learning and improvement, 4) interpersonal and communication skills, 5) professionalism, and 6) systems-based practice.

The timeline for implementation of the ACGME outcomes project—i.e., the timeline for phasing in the new competency requirements—has been divided into four phases:

· Phase 1: by 2002, we must make a preliminary response to the new requirements and begin to integrate the competencies into our curriculum.

· Phase 2: from2002-2006, we are expected to provide evidence of learning in the six prescribed competencies, and develop and improve assessment tools to measure competence.

· Phase 3: beginning in 2006, we are mandated to provide evidence of learning and assessment in all competencies. These assessments are expected to provide the basis for program evaluation and improvement.

· Phase 4: by 2011, we are expected to identify best practice models that can be shared among disciplines and with the community.

Before the new ACGME requirements became widely known, the Ambulatory Pediatric Association (APA) was already planning a revision of the 1996 Educational Guidelines for Residency Training in General Pediatrics, in order to address five years of changes in the science and practice of pediatrics. The APA has decided that the revised Guidelines should go beyond updating information and address the challenge of helping programs to negotiate the paradigm shift to competency-based education.

This challenge has forced the Revision Project Team to clarify our collective thinking about how the concept of a “competency” fits into our more familiar educational framework of “goals” and “objectives.” In the 1996 Educational Guidelines, we defined a learning goal as a lofty, global vision of what you ultimately hope your graduates will achieve. Learning objectives were defined as discreet, observable and/or measurable behaviors that in the aggregate demonstrate that a learner has achieved (or made acceptable progress toward) an overarching goal. Simple objectives generally describe a segment of knowledge, a skill, or an attitude of the learner, and more complex objectives combine several of these components of learning.

In our view, the new ACGME competencies are something of a hybrid between goals and objectives. They resemble goals in that they encompass a complex array of related knowledge, skill, and attitude components. Their breadth is evident from the fact that the six competencies—patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice—are being applied by the ACGME in similar form to all medical specialties. However, unlike a typical goal, these broad competencies are expected to be measurable, as are learning objectives. In fact, they are expected to be measured whenever possible by performance-based evaluation methods, which suggests a considerably higher standard of evaluative documentation than most programs have met in the past. The combination of the very wide breadth of content encompassed by the ACGME competencies and the requirement that they be measured is challenging to program directors.

The Guidelines Revision Project Team (which includes some of those residency program directors, by the way), is most sympathetic with the angst caused by the paradigm shift to competencies. After very extended discussions, we have come to the following consensus view:

· The move toward more rigorous documentation of graduate performance outcomes is going to happen (whether we like it or not).

· The details of what will actually be required of programs for accreditation is not yet clear to anyone.

· We need to move toward improved clarity in our educational expectations of graduates and their teachers (i.e., our goals and objectives for learners), and toward improved evaluation methods, to prepare for the new accreditation requirements that are promised over the next decade.

In consequence, the revised Guidelines will reflect the need by pediatric residency programs to develop a competency-based curriculum that is built on behaviorally defined and measurable objectives.

· The goal statements in the new Guidelines will use behavioral language to make them more descriptive of performance outcomes.

· The objective statements will be phrased with reference to behaviors expected of exiting residents.

· The document will not be organized around the new ACGME competencies, but all the goals and objectives will be linked to the broad competency(s) under which they fall. The primary display format of the document will be organized around a topic-specific curriculum approach, as in the previous edition.

· Given the need for flexibility in the coming years, as ACGME accreditation standards evolve, the new Guidelines will be available on the APA website. As a web-based document, it will be much easier than the old print version for program directors to access and edit to meet their individual and changing program needs. The website will give access to several format options that reflect different sorting principles. And finally, future updating of the Guidelines will also be easier and cheaper when the document is online.

In summary, then, the ACGME has mandated a shift in graduate medical education to focus on broad competencies that must be documented at the residency program level by a demonstration of graduate performance outcomes. By 2006, we as educators will be accountable for documenting evidence of resident learning and assessment that is tied to the six prescribed competencies. At that time, we will also be embarking on the next phase of the ACGME timeline, where we must provide evidence of learning and assessment in all competencies and use this information for program improvement. The APA hopes to help pediatric residency programs meet the challenge posed by the ACGME, and ultimately by Congress. We propose to coordinate the efforts of invested and expert educators by offering a set of updated learning goals and objectives, linked to the six broad ACGME competencies, which can be used as a template by residency programs to develop and build their own competency-based curriculum that meets future accreditation standards.

For more information on the ACGME Outcome Project, see http://www.acgme.org/. [Accessed 2/6/02] The Accreditation Council for Graduate Medical Education, Chicago, Illinois.