A year ago, I wrote in this space about implementation of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project in ophthalmology (Ophthalmology Times, Nov. 1, 2008, Pages 4 and 6). Graduate medical education (GME) has been based historically on a proven tradition known colloquially in education circles as the apprenticeship model. I trained and taught under this apprenticeship model and its central philosophy of "see one, do one, teach one."
Unfortunately, real patients were and remain the subjects of the model, and "see one, do one, teach one" sometimes did not occur in that order. Thus, the apprenticeship model suffers from inherent limitations that have called into question not only the safety but the quality, appropriateness, and effectiveness of the training model for residents. External stakeholders in the educational process, including the public, the payers, and the government, have called for reform in the GME process and for transformation from the apprenticeship model to a competency-based model of education.
In the competency-based model, learners and teachers would be asked to provide proof of quality, evidence of learning, and tangible, data-driven, external outcome measures of success.
In addition, as in the airline industry, simulation technology would be expected to replace live patients for modeling failure scenarios by testing cognitive ability and stress reaction times to various conditions without patient risk. Core improvement strategies such as root cause analysis and efficiency and quality improvement studies also could be transferred from industry applications to medicine.
The old apprenticeship model for individual learning was paired with an accreditation model that emphasized structure and process as well as minimum surgical numbers, and it only required documentation of teaching. The new competency model of accreditation will emphasize outcomes over structure/process, will require demonstration of competency in surgery, and will demand evidence for learning as well as teaching.
In our traditional GME paradigm, individuals attended an ACGME-accredited institution and then after graduation were certified (usually by a written qualifying and oral examination format) by the specialty board (for instance, the American Board of Ophthalmology).
In the competency-based paradigm, individuals will have to provide evidence for competency beyond the structure/process requirements of the old accreditation model. Program directors and chairpersons in ophthalmology are being asked to "sign off" on the competency of their graduates and, thus, the high-stakes decision and the competency burden of proof has fallen onto individual programs.
To ensure that this decision is supported by evidence of quality, new tools have been developed to assess individual and programmatic competence in key competencies. Each individual training program's objective for teaching and assessing resident competence in the competencies ideally would align with the parallel, but over-arching, professional and societal goals of aggregate, programmatic improvements in health care for individual patients and for the system at large.
Only with external data-driven outcome measures will the stakeholders, including the learners themselves, be assured of quality in GME. These outcome measures ideally would reflect downstream tangible benefits including improved patient safety, reduced medical error, increased patient quality, reduced cost or better utilization of services, and improved patient satisfaction.