Domain of Competence: Patient Care · 2015. 11. 6. · Competency 2. Organize and prioritize responsibilities to provide patient care that is safe, effective, and efﬁcient Daniel

COMPETENCIES

Domain of Competence: Patient Care

Daniel J. Schumacher, MD, MEd; Robert Englander, MD, MPH; Patricia J. Hicks, MD, MHPE;Carol Carraccio, MD, MA; Susan Guralnick, MD

From the Boston Combined Residency Program in Pediatrics, Pediatric Emergency Medicine, Boston Medical Center, Boston, Mass (DrSchumacher); Association of American Medical Colleges, Washington, DC (Dr Englander); Department of Clinical Pediatrics, PerelmanSchool of Medicine at the University of Pennsylvania, Philadelphia, Pa (Dr Hicks); Competency-Based Assessment, American Board ofPediatrics, Chapel Hill, NC (Dr Carraccio); and Office of Graduate Medical Education and Student Affairs, and Department of Pediatrics,Winthrop University Hospital, Mineola, NY (Dr Guralnick)The views expressed in this report are those of the authors and do not necessarily represent those of the Accreditation Council for GraduateMedical Education, the American Board of Pediatrics, the Association of Pediatric Program Directors, or the Academic Pediatric Association.The authors declare that they have no conflict of interest.Publication of this article was supported by the American Board of Pediatrics Foundation and the Association of Pediatric Program Directors.Address correspondence to Daniel J. Schumacher, MD, MEd, One Boston Medical Center Place, Boston, MA 02118 (e-mail: daniel.
[email protected]).
KEYWORDS: pediatrics; residency; graduate medical education;undergraduate medical education; competency based education;patient care

ACADEMIC PEDIATRICS 2014;14:S13–S35

THE PATIENT CARE domain contains the greatest numberof competencies of the 7 domains of competence consid-ered by pediatrics. Combined with a historical emphasison the central nature of patient care to physician practice,it may be tempting to assume the number of competenciesin this domainmeans it is the most important or is sufficientto stand alone. On the contrary, looking beyond patient careto the other domains is essential to meeting the Institute ofMedicine goals of providing care that is safe, effective, effi-cient, patient centered, timely, and equitable.1 Further, thecompetencies in the domain of patient care are far from in-dependent. Indeed, much overlap exists between many ofthe patient care competencies and competencies in otherdomains, such as interpersonal and communication skills,professionalism, personal and professional development,and medical knowledge.

Looking within the domain of patient care, there is afocus on competencies that go beyond the traditionalemphasis on taking a history, performing a physical exam-ination, and managing a patient’s illness. In an era of focuson patient safety and duty hours limitation, transfer of care

ACADEMIC PEDIATRICSCopyright ª 2014 by American Board of Pediatrics andAccreditation Council for Graduate Medical Association

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emerges as a critical competency. While clinical reasoningmay already be considered a foundational aspect of patientcare, we hope to draw attention to it in both curriculum andassessment of learners through defining explicit milestonesfor this competency. Finally, optimal patient care goesbeyond competencies addressing the relationship betweenthe physician and the patient and family. It is also includesthe relationship between supervisors and trainees, necessi-tating competencies focusing on role modeling what itmeans to provide patient-centered care and the dance be-tween the supervisor and the supervisee that balancessafe care of the patient with the professional growth ofthe learner.2

REFERENCES

1. Institute ofMedicine Committee onQuality of Health Care in America.

Crossing the Quality Chasm: A New Health System for the 21st Cen-

tury. Washington, DC: National Academies Press; 2001.

2. Balmer DF, Giardino AP, Richards BF. The dance between attending

physicians and senior residents as teachers and supervisors. Pediatrics.

2012;129:910–915.

Competency 1. Gather essential and accurate information about the patient

Daniel Schumacher, MD, MEd

BACKGROUND: EARLY DEVELOPMENT OF INFORMATION- which are representations of how things are related and
GATHERING SKILLS
In the early stages of clinical reasoning, learners mustrely upon their knowledge of basic pathophysiology andprinciples learned in their preclinical training when theygather information about patients. This knowledge allowsthem to use analytic reasoning to generate mental maps,

linked to one another. In this situation, mental maps repre-sent theway in which components of a patient’s history andphysical examination are linked to one another as well as tothe possible diagnoses.1–5With limited clinical experience,these mental maps can be both overly extensive and inap-propriately convoluted, including information of no or

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S14 PATIENT CARE ACADEMIC PEDIATRICS

limited clinical relevance to the patient’s current presenta-tion. At the same time, the lack of clinical experience mayresult in neglecting important features of the history andexamination. The end result is often limited connectionsbetween the pieces of information gathered.

INTERMEDIATE DEVELOPMENT OF INFORMATION-GATHERING

SKILLS

As they gain exposure to clinical practice, learnersbegin to link signs and symptoms of their current patientto patterns of signs and symptoms they have seen in pre-vious patients. With increasing clinical experience,learners use these prior clinical encounters to helpthem filter and group the information gathered intomore specific diagnostic categories and then graduallyadvance to creating illness scripts. These scripts arebased on recognizing patterns of signs and symptomsseen in previous clinical encounters and can be thoughtof as mental scaffolding representing the characteristicfeatures of specific illnesses.1–6 Illness scripts are uniqueto each physician and become more robust withadvancing clinical experience. As an example, the earlydevelopment of an illness script for group A strepto-coccal pharyngitis may include fever, throat pain, andoropharyngeal erythema with exudates on examination.With further clinical experience, this illness script mayadvance to include the additional features of headache,abdominal pain, malaise, tender anterior cervical lymph-adenopathy, and palatal petechiae. With still furtherexperience, this illness script may advance to includefeatures such as Pastia lines and circumoral pallor. Asillustrated in this example, illness scripts become morerobust and discriminating as they develop, allowing thephysician to become more facile and exacting in gath-ering essential and accurate information about hispatients.

ADVANCED DEVELOPMENT OF INFORMATION-GATHERING

SKILLS

As clinical expertise continues to develop, practi-tioners move from using prototypical illness scripts tocreating more robust and elaborate scripts that incorpo-rate specific characteristics of individual patients to form“instance” scripts.1 Recognition and use of these subtlevariations in disease and patient characteristics help todiscriminate features of similar illnesses and enhancethe precision and accuracy with which clinical informa-tion is gathered, thereby avoiding premature closure inthe development of a differential diagnosis.1,2 In theexample of pharyngitis, this clinician would be open tothe unexpected and may consider the possibility of apseudomembrane when tonsillar exudate appears atyp-ical. The clinician may subsequently suspect a diagnosisof diphtheria, even though many clinical characteristicsoverlap with group A streptococcal pharyngitis (throatpain, fever, headache, malaise, nausea, and cervicallymphadenopathy).

In the progression of information gathering, it isimportant not to misperceive pattern recognition as ahigher-order cognitive process than analytic reasoning.Rather, the increased use of pattern recognition withadvancing clinical experience simply represents thenatural progression of information-gathering skills.2

However, even master clinicians engage in analyticreasoning when presented with rare cases not previouslyencountered in practice.

DEVELOPMENTAL MILESTONES:

� Relies on a template to gather information that is not based on thepatient’s chief complaint, often either gathering too little or toomuch information in the process. Recalls clinical information in theorder elicited,7 with the ability to gather, filter, prioritize, and connectpieces of information being limited by and dependent upon analyticreasoning through basic pathophysiology alone.

�Relies primarily on analytic reasoning through basic pathophysiologyto gather information, but the ability to link current findings to priorclinical encounters allows information to be filtered, prioritized, andsynthesized into pertinent positives and negatives as well as broaddiagnostic categories.

�Gathers information while it is simultaneously filtered, prioritized, andsynthesized into specific diagnostic considerations (usingadvanced development of pattern recognition that leads to creationof illness scripts to accomplish this). Data gathering is driven by real-time development of a differential diagnosis early in the information-gathering process.8

� Gathers essential and accurate information to reach precisediagnoses with ease and efficiency when presented with mostpediatric problems (using well-developed illness scripts toaccomplish this), but still relies on analytic reasoning through basicpathophysiology to gather information when presented withcomplex or uncommon problems.

� Demonstrates effortless gathering of essential and accurateinformation in a targeted and efficient manner when presented withall but the most complex or rare clinical problems (using robustillness and instance scripts to accomplish this—instance scriptsadd specific details of individual patients to illness scripts). Able todiscriminate among diagnoses with subtle distinguishing features.

REFERENCES

1. Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on

medical expertise: theory and implications. Acad Med. 1990;65:

611–621.

2. Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educa-

tional bench to the clinical bedside: translating the Dreyfus Develop-

mental Model to the learning of clinical skills. Acad Med. 2008;83:

761–767.

3. Eva K. What every teacher needs to know about clinical reasoning.

Med Educ. 2004;39:98–106.

4. Schmidt HG, Boshuizen HPA. On acquiring expertise in medicine.

Educ Psychol Rev. 1993;5:205–221.

5. Schmidt HG, Rikers RMJP. How expertise develops in medicine:

knowledge encapsulation and illness script formation. Med Educ.

2007;41:1133–1139.

6. Charlin B, Boshuizen HPA, Custers EJ, Feltovich PJ. Scripts and clin-

ical reasoning. Med Educ. 2007;41:1178–1184.

7. Patel VL, Groen GJ, Patel YC. Cognitive aspects of clinical perfor-

mance during patient workup: the role of medical expertise.AdvHealth

Sci Educ. 1997;2:95–114.

8. Elstein AS, Kagan N, Shulman LS, et al. Methods and theory in the

study of medical inquiry. Journal of Med Educ. 1972;47:85–92.






















ACADEMIC PEDIATRICS PATIENT CARE S15

Competency 2. Organize and prioritize responsibilities to provide patient care that is safe,effective, and efficient


BACKGROUND: In the 2001 report, Crossing the QualityChasm: A New Health System for the 21st Century, theInstitute of Medicine (IOM) describes “the prevailingmodel of health care delivery [as] complicated, comprisinglayers of processes and handoffs that patients and familiesfind bewildering and clinicians view as wasteful . . . and fail[ing] to build on the strengths of all health professionalsinvolved to ensure that care is timely, safe, and appro-priate.”1 The IOM described 6 aims for improvement:safety, effectiveness, patient-centeredness, timeliness, effi-ciency, and equality in patient care. With this in mind, thiscompetency for organizing and prioritizing responsibilitiesto provide patient care that is safe, effective, and efficientfinds important relationships with several other compe-tencies in all competency domains. Given the broad anddeep relationships to other competencies that address theprovision of patient care that is safe, effective, and efficient(second half of the current competency), this competencywill focus on the skills needed for organization and priori-tization of this care (first half of the current competency)from the perspective of how these skills can lead to carethat is safe, effective, and efficient.TIME MANAGEMENT: When considering the organizationand prioritization of responsibilities to provide patientcare, timemanagement is an important element of the foun-dation. Covey’s time management matrix technique(TMMT) provides a useful construct for consideration.2

In the TMMT, all activities are placed into 1 of 4 quadrantson the basis of their relative importance and urgency as fol-lows: quadrant I—important and urgent; quadrant II—important and not urgent; quadrant III—not importantand urgent; and quadrant IV—not important and not urgent.

As Covey describes, the goal is to organize and prioritizeresponsibilities such that they fall within quadrant II(important and not urgent), which focuses on planningahead, being proactive, and optimizing productivity. Incontrast, quadrant I (important and urgent), which focuseson being reactive and responding to crises, should beavoided as much as possible. In clinical practice, it is some-times not possible to avoid emergent situations, as patientscan acutely decompensate without warning. In this situa-tion, working in quadrant I (important and urgent) is inev-itable and unavoidable. However, even in clinicalmedicine, being proactive and astutely aware of the currentsituation can allow one to anticipate and avoid many crises,maximizing functioning in quadrant II (important and noturgent) and minimizing transitions into quadrant I (impor-tant and urgent). An example of this is the night roundsdone by the junior and senior members of the health careteam leading to the discovery of and intervention on behalfof a child with worsening respiratory distress, thereby pre-venting the child’s eventual respiratory failure.

The activities of quadrant III (not important and urgent)include interruptions as well as required unproductivework (eg, attending a poorly run meeting in which nothingmeaningful is accomplished). These activities are alsosometimes unavoidable in clinical practice. However,they can also be anticipated and proactively avoided attimes (remaining in quadrant II [important and not urgent]and avoiding a transition to quadrant III [not important andurgent]). An example of this is the physician who makessure to address the questions and concerns of the multidis-ciplinary team and family on bedside rounds to preventsome pages, which serve as interruptions,3–5 as he con-tinues his work for the day.While the activities of quadrant IV (not important and

not urgent) are not important in terms of organizing andprioritizing responsibilities for patient care, they can serveas important outlets for maintaining work–life balance,reducing stress, and enhancing personal and career satis-faction (eg, the physician who reads a good mystery novelfor 20 minutes during lunch, when able, as an enjoyableescape from the workday).MULTITASKING AND MINIMIZING INTERRUPTIONS: In addi-tion to time management, important foundational elementsof organizing and prioritizing patient care responsibilitiesinclude 1) the optimization of multitasking and 2) the mini-mization and successful navigation of interruptions. Thenature of work in the emergency department has led toseveral articles describing the frequent interruptions andmultitasking,6–9 which can lead to lapses in informationtransfer, that occur in that environment.6 Unfortunately,these activities can compromise the safe and effectivecare of patients, an important consideration when viewingthis competency in its entirety. The next 2 sections there-fore describe the role of these elements in the safe andeffective, as well as efficient, organization and prioritiza-tion of responsibilities.OPTIMIZATION OF MULTITASKING: While multitasking canimpair the safe and effective care of patients, it can alsobenefit the efficiency of that care. Among emergencymedicine residents, work efficiency is enhanced notonly by clinical experience but also by the ability to mul-titask well.8 Therefore, the optimization of multitasking isan important skill in developing in this competency. Thework of Chisholm et al9 underscores the importance ofthis in pediatrics. The authors showed that while emer-gency medicine physicians have more interruptions andspend more time simultaneously managing more than 1patient, office-based primary care physicians spendmore time performing simultaneous tasks. Similarly,O’Leary and colleagues5 found that hospital-based inter-nal medicine physicians spent 21% of their time multi-tasking.

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MINIMIZATION OF AND RESPONSE TO INTERRUPTIONS:Multitasking and interruptions are closely related inmany ways. Increasing interruptions often leads to theincreased need for multitasking. Therefore, minimizing in-terruptions can benefit the optimization of multitasking.The minimization of interruptions was previously dis-cussed briefly as it relates to time management. Theresponse to interruptions will be addressed here.

The literature reports a variable response to interruptions.Brixey and colleagues10 noted that emergency medicine at-tendingsmost often responded to an interruptionwith a briefbreak in task followed by a return to the same preinterruptedtask. However, they note that O’Conaill and Frohlich11

found that 41% of interruptions in the office workplacelead to a permanent break in task in which there is no returnto the preinterrupted task. While there are urgent and emer-gent interruptions in clinicalmedicine that necessitate a pro-longed or permanent break in task (eg, a physician isexamining a child in the emergency department with viralconjunctivitis when another child begins seizing and be-comes apneic), most responses to interruptions in the clin-ical setting are likely related to the developmental level ofthe individual being interrupted. When early in clinicalexperience, interruptions are more likely to lead to a pro-longed or permanent break in the present task to respondto the interrupting task. This can be true evenwhen the inter-rupting task is less important. For these learners, permanentbreaks in task are likely secondary to forgetting about thepreinterrupted task altogether. As Brixey and colleagues10

demonstrate, individuals with more advanced clinical expe-rience are more likely to respond to an interruption with abrief break in task,with return to the preinterrupted task afterthe interruption. They are alsomore likely to prioritize inter-ruptions and address them in order of importance.


� Organizes patient care responsibilities by focusing on individualpatients rather than multiple patients; responsibilities are prioritizedas a reaction to unanticipated needs that arise (thoseresponsibilities presenting the most significant crisis at the time aregiven the highest priority); even small interruptions in task often leadto a prolonged or permanent break in that task to attend to theinterruption, making return to initial task difficult or unlikely.

� Organizes the simultaneous care of a few patients with efficiency;occasionally prioritizes patient care responsibilities to anticipatefuture needs; each additional patient or interruption in work leads todecreases in efficiency and ability to effectively prioritize; permanentbreaks in task with interruptions are less common, but prolongedbreaks in task are still common.

� Organizes the simultaneous care of many patients with efficiency;routinely prioritizes patient care responsibilities to proactivelyanticipate future needs; additional care responsibilities lead todecreases in efficiency and ability to effectively prioritize only whenpatient volume is quite large or there is a perception of competingpriorities; interruptions in tasks are prioritized and only lead toprolonged breaks in task when workload or cognitive load is high.

� Organizes patient care responsibilities to optimize efficiency; providescare to a large volume of patients withmarked efficiency; patient careresponsibilities are prioritized to proactively prevent those urgent andemergent issues in patient care that can be anticipated; interruptionsin task lead to only brief breaks in task in most situations.

Serves as a role model of efficiency; patient care responsibilities areprioritized to proactively prevent interruption by routine aspects ofpatient care that can be anticipated; unavoidable interruptions areprioritized to maximize safe and effective multitasking ofresponsibilities in essentially all situations.

REFERENCES

1. Institute of Medicine Committee on Quality of Health Care in

America. Crossing the Quality Chasm: A New Health System for

the 21st Century. Washington, DC: National Academies Press;

2001.

2. Covey S. The Seven Habits of Highly Effective People. NewYork, NY:

Simon & Schuster; 1989.

3. BlumNJ, Lieu TA. Interrupted care: the effects of paging on pediatric

resident activities. Am J Dis Child. 1992;146:806–808.

4. Wong BM, Quan S, Shadowitz S, Etchells E. Implementation and

evaluation of an alphanumeric paging system on a resident inpatient

teaching service. J Hosp Med. 2009;4:E34–E40.

5. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend

their time: insights on efficiency and safety. J Hosp Med. 2006;

1:88–93.

6. Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking

clinician: decision-making and cognitive demand during and after

team handoffs in emergency care. Int J Med Inform. 2007;76:

801–811.

7. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency

department workplace interruptions: are emergency physicians

“interrupt-driven” and “multitasking”? Acad Emerg Med. 2000;7:

1239–1243.

8. Ledrick D, Fisher S, Thompson J, Sniadanko M. An assessment of

emergency medicine residents’ ability to perform in a multitasking

environment. Acad Med. 2009;84:1289–1294.

9. Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH. Work inter-

rupted: a comparison of workplace interruptions on emergency

department and primary care offices. Ann Emerg Med. 2001;38:

146–151.

10. Brixey JJ, Tang Z, Robinson DJ, et al. Interruptions in a level one

trauma center: a case study. Int J Med Inform. 2008;77:235–241.

11. O’Conaill B, Frohlich D. Timespace in the workplace: dealing with

interruptions. In: Proceedings of the Conference in Human Factors

on Computing Systems. New York, NY: Association for Computing

Machinery; 1995.

Competency 3. Provide transfer of care that ensures seamless transitions

Robert Englander, MD, MPH

BACKGROUND: With the advent of work duty hours and theInstitute of Medicine reports on patient safety of the pastdecade, the skill of transferring care between providersand teams hasbecomeparamount. The literature on teachingand assessinghandoff communication has proliferated in the

realms of nursing,1,2 patient safety,3 medical education,4,5

andmedical specialties.6,7Handoffs occur in avariety of set-tings and contexts. For example, handoffs may occur withinunits, betweenunits, between specialists and generalists, be-tween subspecialists in different specialties, or between
































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inpatient andoutpatient settings. In addition, theymay occurin person, by telephone, or by written document.

Emerging from the literature is a developmental progres-sion in this skill, both at the individual and system levels.Novice systems and individuals have in common a lack ofstandardization in the process. There is variability in the con-tent, efficiency, accuracy, and synthesis of information bothwithin and between individuals handing off on different pa-tients. In addition, Arora and Johnson3 observed significantvariability in the process between teams, departments, units,and different hospitals or clinical settings within a system.The foundation of developmental progression in this skillis the development and use of standardized templates for in-formation exchange. Many templates have been provided inthe literature.2 To some extent, this stage of development re-quires support from the system in which the practitionerpractices. The advanced beginner may use the template buthas minimal ability to abstract pertinent information or addpertinent information beyond the script. As one becomesproficient, one can reliably and reproducibly transfer thepertinent information using and adapting the template.Assessment of this level of skill has been demonstratedthrough observed structured clinical examinations (OSCEs).The progression to competence includes becoming moresuccinct, avoiding errors of commission and omission, andimproving one’s ability to anticipate events and responsesfor the practitioner accepting responsibility. In addition, thecompetent practitioner in this skill facilitates the opportunityfor the receiving caregiver to read back, repeat back, or ques-tion any critical information.2 The competent receiving care-giver of handoff information also takes ownership forensuring understanding of the information and using deliber-ative inquiry to fill in any perceived gaps.

As one advances beyond the competent stage, one be-comes increasingly agile in communicating the right infor-mation in a succinct manner in increasingly complex,demanding, and specialty-specific situations.5 The expertand master stages in handoff communication also involvesuperimposing a critical element of professionalism onthis skill, that is, the transfer of professional responsibility.3

Even when separated in time or space, the master in hand-off communication makes clear to patients, families, andmembers of the health care team when the professional re-sponsibility for the patient has changed. On the part of thetransferor, that professional responsibility includes transferof all pertinent information for both active and anticipatedissues during the ensuing time period. For the transferee, itincludes the responsibility to obtain clarity and to assume

responsibility once clarity around the patient’s issues hasbeen provided, whether that responsibility is to last anhour, a shift, a week, or longer. For the individual assessinghandoff communication, the master would never think norutter the words, “I am just cross-covering.”


� Demonstrates variability in transfer of information (content,accuracy, efficiency, and synthesis) from one patient to the next.Frequent errors of both omission and commission in the handoff.

� Uses a standard template for the information provided during thehandoff. Unable to deviate from that template to adapt to morecomplex situations. May have errors of omission or commission,particularly when clinical information is not synthesized. Neitheranticipates nor attends to the needs of the receiver of information.

� Adapts and applies a standardized template, relevant to individualcontexts, reliably and reproducibly, with minimal errors of omissionor commission. Allows ample opportunity for clarification andquestions. Beginning to anticipate potential issues for thetransferee.

� Adapts and applies a standard template to increasingly complexsituations in a broad variety of settings and disciplines. Ensuresopen communication, whether in the receiver- or provider-of-information role through deliberative inquiry, including but notlimited to read-backs, repeat-backs (provider), and clarifyingquestions (receivers).

� Adapts and applies the template without error and regardless ofsetting or complexity. Internalizes the professional responsibilityaspect of handoff communication, as evidenced by formal andexplicit sharing of the conditions of transfer (eg, time and place) andcommunication of those conditions to patients, families, and othermembers of the health care team.

REFERENCES

1. Amato EJ, Barba MP, Vealey RJ. Hand-off communication: a requisite

for perioperative patient safety. AORN J. 2008;88:763–770.

2. Sandlin D. Improving patient safety by implementing a standardized

and consistent approach to hand-off communication. J Perianesth

Nurs. 2007;22:289–292.

3. Arora V, Johnson J. A model for building a standardized hand-off pro-

tocol. J Qual Patient Saf. 2006;32:646–655.

4. Kalet A, Pugnaire MP, Cole-Kelly K, et al. Teaching communication in

clinical clerkships: models from the Macy initiative in health commu-

nications. Acad Med. 2004;79:511–520.

5. Duffy FD, Gordon GH, Whelan G, et al. Assessing competence in

communication and interpersonal skills: the Kalamazoo II report.

Acad Med. 2004;79:495–507.

6. BrinkmanWB,Geraghty SR, Lanphear BP, et al. Evaluation of resident

communication skills and professionalism: a matter of perspective? Pe-

diatrics. 2006;118:1371–1379.

7. Fletcher KE, Wiest FC, Halasyamani L, et al. How do hospitalized pa-

tients feel about resident work hours, fatigue, and discontinuity of care?

J Gen Intern Med. 2008;23:623–628.

Competency 4. Interview patients/families about the particulars of the medical condition forwhich they seek care, with specific attention to behavioral, psychosocial, environmental, andfamily-unit correlates of disease


BACKGROUND: Models that shine light on the behavioral,psychosocial, environmental, and family-unit correlates

of health and disease critical in the medical interview focuson the therapeutic relationship formed between the




















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physician and the patient and family rather than on an act ofinformation gathering driven by the physician.1,2 With thisin mind, wewill use the termmedical encounter rather thaninterview when considering this competency.

Ideally, the medical encounter serves 3 functions: gath-ering biological and psychosocial information, respondingto the emotions of patients and families, and educating pa-tients and families to ensure optimal outcomes.1 Theencounter can be divided into 4 functional components:building a relationship, data gathering, patient educationand counseling, and activating and partnering.2–4 Buildingon this construct as well as on the work of Freire,5 Roter6

has conceptualized the developmental continuum of physi-cians’ skills in facilitating the involvement of patients intheir care as beginning with patient participation and

Table 1. Developmental Continuum of Facilitating Patient and Family In

Data Gathering Skills Re

ADVANCINGDEVELOPMENT

Doctor

Participation

Closed questions. Negadisdiscrit

Patient

and/or

Family

Participation

Open questions, elicitingtopics/chief concernsfor the medicalencounter at thebeginning of theencounter and jointlyprioritizing the topics.1

Not inemres(incsucreaexplegandengconclasum

Patient and/or

Family

Activation

As above under patientand/or familyparticipation.

As abpafampa

Empowerment

Facilitation

As above under patientand/or familyparticipation as wellas patient and/orfamily activation.

As abpafamasandact

moving to patient activation and then empowerment facil-itation. We also propose a developmental stage before this,in keeping with the work of Roter, which we have labeled“doctor participation” because this stage includes be-haviors that do not engage the patient and/or family toparticipate. The components of these participatory com-munications skills are shown in Table 1.As this construct illustrates, the recognition and sensi-

tivity toward the verbal and nonverbal cues and state-ments from the patient and/or family are important inguiding the encounter as well as in forming a therapeuticrelationship with the patient and family that will lead toempowering them with their own health care. Forexample, not interrupting, showing empathy, and express-ing concern with a teen presenting for a health supervision

volvement (adapted from the work of Roter6)

lationship Skills Partnering Skills

Patient Education

and Counseling

tive talk (eg,agreements,approval,icism).

None. Unilateral, prescriptive,and/or otherwisedoctor- centerededucation withoutconsideration ofthe patient and/orfamily’s needs.

terrupting,otionalponsivenessludes behaviorsh as empathy,ssurance,ressing concern),itimizing feelingsthoughts,aging in socialversation,4,7

rifying andmarizing.7

Showing interestthrough verbaland nonverbalbehaviors,paraphrasingthe patientand/or familymember,avoiding verbaldominance inthe conversation.

Sharing informationdesired by thepatient and/orfamily

ove undertient and/orily

rticipation.

As above underpatient and/orfamilyparticipation.Additionally,asking forpatient andfamilyexpectations,opinions, andsuggestionsand engagingin joint problemsolving with thepatient andfamily (sharingcontrol1).

As above underpatient and/orfamily participation.

ove undertient and/orily participationwell as patient/or familyivation.

As above underpatient and/orfamily activation.Additionally,brainstormingoptions jointlyand negotiation.

Verification ofinformation andcounseling abouttreatment, lifestyle,and psychosocialissues; motivationalinterviewing.1


visit can prompt further information gathering that leadsto the diagnosis of pregnancy, with subsequent formationof a vital therapeutic partnership and counseling that fa-cilitates empowering her to share in decision makingabout care options.8

In the developmental trajectory of physicians’ skills infacilitating the participation of patients in their caredescribed above, it should also be noted that early in theirdevelopment, physicians will tend to focus on gatheringbiomedical information, whereas later in developmentthey will include elicitation and then joint decision mak-ing and counseling around psychosocial issues as well.Additionally, as physicians continue to develop theircommunication skills with a deliberate focus on thebehavioral, psychosocial, environmental, and family-unit correlates of disease, more advanced skills are incor-porated as well. These include using understanding ofpersonality type and communication style of self andothers to tailor and optimize communication as well asperceiving and responding appropriately to defensemechanisms (eg, silence, denial, attacking back, blamingothers, and changing the subject) in critical conversa-tions.1

Previous studies9,10 have shown declination in interper-sonal communication skills with advancing medical educa-tion. This may not be surprising given that the emphasis onteaching medical interviewing skills is limited to early inthe undergraduate medical education curriculum. Giventhat competence is a habit11 and that skill maintenance de-pends on deliberate practice,12 the continued focus on thesefoundational skills throughout the graduate medical educa-tion years is important.


� Focuses themedical encounter on gathering biomedical informationimportant to the health care provider rather than using abiopsychosocial model that includes information important to thepatient/family as well. Patients’ and families emotional cues andexpressions are not noticed and/or not acknowledged.

� Forms a therapeutic relationship through patient and familyparticipation in eliciting both biomedical and psychosocialinformation. Responds to patients’ and families’ emotional cuesand expressions in a manner that shows respect andacknowledges their role in the encounter, but does not yet build apatient-centered therapeutic alliance that allows for shared decisionmaking and counseling.

� Shares control of the medical encounter to create a therapeuticrelationship with patients and families that aims to activate andempower them. Responds to emotional cues and expressions in amanner that allows themedical encounter to go beyond informationgathering to focus on joint problem solving, shared decisionmaking, and counseling, being sensitive to the developmental levelof the child and his/her role in this process.

� Tailors the encounter to optimize communication based on thepersonality type and communication style of self and others;advanced and dynamic perception of and response to emotionsfosters a patient-centered therapeutic relationship even in difficultencounters (eg, the delivery of bad news or counseling a defensivepatient).

� Current literature does not distinguish between behaviors ofproficient and expert practitioners. Expertise is not an expectationof GME training, as it requires deliberate practice over time.

REFERENCES

1. Bird J, Cohen-Cole SA. The three-function model of the medical

“interview”: an educational device. Adv Psychosom Med. 1990;20:

65–88.

2. Roter DL, Larson S. The relationship between residents’ and

attending physicians’ communication during primary care visits: an

illustrative use of the Roter Interaction Analysis System.Health Com-

mun. 2001;13:33–48.

3. Roter DL, Larson S. The Roter Interaction Analysis System (RIAS):

utility and flexibility for analysis of medical interactions. Patient

Educ Couns. 2002;46:243–251.

4. Roter DL, Hall JA. Physician gender and patient-centered communi-

cation: a critical review of empirical research. Annu Rev Public

Health. 2004;25:497–519.

5. Freire P. Education for Critical Consciousness. New York, NY: Con-

tinuum Press; 1983.

6. Roter D. The medical visit context of treatment decision-making and

the therapeutic relationship. Health Expect. 2000;3:17–25.

7. Del Piccolo L, Mead N, Gask L, et al. The English version of the Ver-

ona Medical Interview Classification System (VR-MICS): an assess-

ment of its reliability and a comparative cross-cultural test of its

validity. Patient Educ Couns. 2005;58:252–264.

8. Charles C, Gafni A,Whelan T. Decision-making in the patient–physi-

cian encounter: revisiting the shared treatment decision-making

model. Soc Sci Med. 1999;49:651–661.

9. Krauss DR, Robbins AS, Abrass I, et al. The long term effectiveness

of interpersonal skills training in medical school. J Med Educ. 1980;

56:595–601.

10. Engler CM, Saltzman GA, Walker ML, et al. Medical student acqui-

sition and retention of communication and interviewing skills. J Med

Educ. 1981;56:572–579.

11. Leach DC. Competence is a habit. JAMA. 2002;287:243–244.

12. EricssonKA. Deliberate practice and the acquisition andmaintenance

of expert performance in medicine and related domains. Acad Med.

2004;79:S70–S81.

Competency 5. Perform complete and accurate physical examinations


BACKGROUND: The foundation of learning to performcomplete and accurate physical examinations is found inthe deliberate practice of performing examinations onmany patients. Only through ongoing practice can onebecome adept in both performing examination maneuverscorrectly as well as eliciting and recognizing normal and

abnormal findings.1 When considering the pediatric phys-ical examination, flexibility to reorder the approach andagility in performing the maneuvers to maximize their ef-ficacy and efficiency are also foundational to engagingchildren at their developmental level and accommodatingtheir current behavioral states.



































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Trends over the past fewdecades toward reliance upon im-aging modalities over physical examination skills2 and alsoaway from teaching and possessing superior and discrimi-nating physical examination skills during training3–6 haveled Bordage to ask, “Where have the history and the physicalexamination gone?”7 In an editorial bearing a similar name,Bordage7 cites the work of Peterson and colleagues,8 whoshowed that while history is the major determinant leadingto a final diagnosis among the physicians they studied, phys-ical examinations were important in excluding and confirm-ing diagnostic hypotheses. In short, performing completeand accurate physical examinations is an important nextstep after performing a complete and accurate history.

Demonstrating the importance of history to examination,Norman and colleagues have shown that approaching thephysical examination with diagnostic hypotheses and theirassociated findings in mind leads to a greater likelihoodof noticing these findings when they are present.9–11

Conversely, approaching the physical examination withoutspecific findings in mind makes someone more likely tomiss thosefindings evenwhen they are present. Furthermore,incorrect diagnostic hypotheses prior to the physical exami-nation can lead to misinterpretation of physical findings (ie,confirmation bias) and attribution of importance and mean-ing to irrelevant findings.9–10 Thus, it is not approachingthe physical examination merely with a list of diagnostic hy-potheses in mind but rather with a more accurate and selectlist of diagnostic hypotheses in mind that is most importantin performing physical examinations that are complete andaccurate and that lead to success in diagnostic reasoning.With this inmind, thematerial discussed in the competenciesof 1) gathering essential and accurate information about thepatient and 2) making informed diagnostic and therapeuticdecisions, both under the Patient Care domain, provide anecessary foundation to this competency of performingphysical examinations.

The findings of LeBlanc, Brooks, Norman and col-leagues9–11 have led others to advocate for a hypothesis-driven physical examination (HDPE), in which learnersmake diagnostic hypotheses before examining a patient,over the standard head-to-toe examination, in whichlearners perform a complete examination with minimal orno regard given to the presenting complaint or history (amethod of learning physical examination skills that is com-mon in medical school training).12,13 Through use of theHDPE, the relevance and efficiency of a learner’s physicalexamination maneuvers are enhanced as they mindfullyattend to specificmaneuvers that confirm aswell as discrim-inate between the diagnostic hypotheses being entertained.

While it is important to use diagnostic hypotheses todrive the physical examination, it is also important toperform a more complete physical examination surveywhen examining patients. Making a habit of routinely per-forming a survey examination helps to develop a range ofnormal findings, gain fluency in executing the maneuvers,and avoid premature closure around a diagnosis bysurveying for findings that may otherwise be missed butwould contribute meaningful information to clinical

reasoning, diagnosis, and/or treatment. Consider as anexample the 12-year-old child without a history of asthmawho presents with bilateral knee pain and whose physiciansuspects Osgood-Schlatter disease but also discoverswheezing on lung examination, which he performs as partof his survey physical examination. Without a careful anddeliberate lung examination, this finding would have goneunnoticed. Here again, however, the mindfulness withwhich this survey examination is performed is paramount.As the work of LeBlanc et al9–11 suggests, if this physicianwere going through the rote steps of a survey examinationwithout anticipating potential findings during each part ofthe examination and being mindful of what he is seeingand hearing, he could still miss the lung finding.The increasing rarity of being taught and possessing su-

perior examination skills during training3–6 underscores theimportance of “making the direct observation of studentsand residents, while they take histories and conduct phys-ical examinations, a major responsibility and activity ofthe faculty. Faculty members could thus give the studentsand residents constructive feedback on the appropriatenessand accuracy of their history-taking and physical-examina-tion techniques and of their interpretation of the findings.”7

DEVELOPMENTALMILESTONES: MILESTONES FOR

THE PERFORMANCE OF THE PHYSICAL EXAMINATION

� Performs and elicits physical examination maneuvers without thecorrect technique

� Performs basic physical examination maneuvers correctly (eg,auscultation of the lung fields) but does not regularly elicit,recognize, or interpret abnormal findings (eg, recognition ofwheezing and crackles).

� Performs basic physical examination maneuvers correctly andrecognizes and correctly interprets abnormal findings.

� Performs, elicits, recognizes, and interprets the findings of basic andmore advanced physical examination maneuvers correctly (eg,Rovsing, psoas, and obturator signs for appendicitis).

� Performs, elicits, recognizes, and interprets the findings of specialtesting physical examination maneuvers correctly (eg, stork test forspondylolysis).

MILESTONES FOR THE APPROACH TO THE PEDIATRIC

PHYSICAL EXAMINATION

� Uses a head-to-toe approach to the physical examination ratherthan a developmental approach.

� Uses a developmentally appropriate approach to the physicalexamination without consistency.

� Uses a developmentally appropriate approach when examiningchildren with consistency; facilitates the engagement of the child aswell as the caregiver in the physical examination.

� Uses a fluid approach and is agile in performing the physicalexamination in a way that maximizes cooperation of the child;facilitates the engagement of the child as well as the caregiver in thephysical examination.



MILESTONES FOR THE APPROACH TO THE FOCUSED

PHYSICAL EXAMINATION

� Applies a rote head-to-toe approach to the physical examination ofthe patient rather than an examination guided by pertinent positiveor negative findings (diagnostic hypothesis testing).

� Conducts examination looking for a myriad of potential positive andnegative physical findings for multiple diagnostic considerations(based on a broad list of diagnostic hypotheses). Using this broadand general approach, misses important physical findings that arepresent, misinterprets physical findings, and/or attributesimportance andmeaning to findings that are not relevant/important.

� Conducts examination looking for specific positive or negativephysical findings of only themost relevant diagnostic considerations(based on a narrow list of diagnostic hypotheses); performs a surveyphysical examination to elicit unexpected abnormalities but may notrecognize these as important when it is difficult to integrate thesefindings into the working differential diagnosis.

� Conducts examination looking for key specific physical findings thatdiscriminate between competing similar diagnoses (in a narrow listof diagnostic hypotheses); uses surprises that result from a surveyphysical examination to rethink and retest diagnostic hypotheses;actively looks for physical examination findings that disconfirm theworking diagnosis or rule in or out rare but high-risk alternativediagnoses.


REFERENCES

1. Erickson KA, Krampe RT, Tesch-Romer C. The role of deliberate

practice in the acquisition of expert performance. Psychol Rev.

1993;100:363–406.

2. Macdessi J, Oates RK. Clinical diagnosis of pyloric stenosis: a

declining art. Br Med J. 1993;306:553–555.

3. Mangione S, Torre DM. Teaching of pulmonary auscultation in pedi-

atrics: a nationwide survey of all US accredited residencies. Pediatr

Pulmonol. 2003;35:472–476.

4. Mangione S, Burdick WP, Peitzman SJ. Physical diagnosis skills of

physicians in training: a focused assessment. Acad Emerg Med.

1995;2:622–629.

5. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal med-

icine and family practice trainees: a comparison of diagnostic profi-

ciency. JAMA. 1997;278:717–722.

6. Mangione S. Cardiac auscultatory skills of physicians-in-training: a

comparison of three English speaking countries. Am J Med. 2001;

110:210–216.

7. Bordage G. Where are the history and physical? Can Med Assn J.

1995;152:1595–1598.

8. Peterson MC, Holbrook JH, Hales DV, et al. Contributions of the his-

tory, physical examination, and laboratory investigation in making

medical diagnoses. West J Med. 1992;156:163–165.

9. LeBlanc VR, Norman GR, Brooks LR. Effect of a diagnostic sugges-

tion on diagnostic accuracy and identification of clinical features.

Acad Med. 2001;76:S18–S20.

10. LeBlanc VR, Brooks LR, Norman GR. Believing is seeing: the influ-

ence of a diagnostic hypothesis on the interpretation of clinical fea-

tures. Acad Med. 2002;77:S67–S69.

11. Brooks LR, LeBlanc VR, Norman GR. On the difficulty of noticing

obvious features in patient appearance. Psychol Sci. 2000;11:

112–117.

12. Yudkowsky R, Bordage G. Lowenstein, Riddle J. Residents antici-

pating, eliciting and interpreting physical findings. Med Educ.

2006;40:1141–1142.

13. YudkowskyR, Otaki J, Lowenstein T, et al. A hypothesis-driven phys-

ical examination learning and assessment procedure for medical stu-

dents: initial validity evidence. Med Educ. 2009;43:729–740.

Competency 6. Make informed diagnostic and therapeutic decisions that result in optimalclinical judgment


BACKGROUND: When considering the developmental pro-gression of making informed diagnostic and therapeuticdecisions that result in optimal clinical judgment, therole of previous clinical experience cannot be emphasizedenough.1–9 With increasing clinical experience, learners donot simply gain new knowledge in an additive manner.Rather, they reorganize existing knowledge in an elabo-rated way that allows them to become more efficient andeffective in diagnosing and treating new patients whopossess features similar to those of previous patients.1–4

This highly learner-specific knowledge is best gainedthrough individual clinical experience, which is a neces-sary but not sufficient prerequisite for developmentaladvancement in making informed diagnostic and therapeu-tic decisions that result in optimal clinical judgment. AsKolb10 suggests in his experiential learning theory, thisknowledge is strengthened through reflective observation,active experimentation (eg, in a simulation environment),and abstract conceptualization. In fact, the mental energythat is saved as one becomes more efficient and effectivein diagnosing and treating new patients must be reinvested

in reflection and new learning if one is ultimately tobecome an expert clinician and not just an experiencednonexpert.11

EARLY CLINICAL REASONING: ANALYTIC REASONING

THROUGH BASIC PATHOPHYSIOLOGY

Development of expert diagnostic and therapeuticreasoning follows a predictable progression.1 In the pre-clinical and early clinical stages, learners rely on knowl-edge of the pathophysiologic causes and consequences ofdisease and analytic reasoning to formulate diagnostic con-siderations. As a result, knowledge is organized as a causalnetwork. At this stage, the learner presented with a childwho has hemolytic uremic syndromemay reason, “Not uri-nating in the past day seems like it could be a problem withthe kidneys’ ability to make urine. The low hemoglobinseems likely to be from hemolysis, which is one of theways that red blood cells can be lost in the body. In thisway, the red blood cells are broken open, often becausethey have fragile structuring on the inside or are havingtrouble passing through certain vessels of the body and






































Delta:1_given name


are being broken from the outside. With the low platelets aswell, I wonder if this child has an illness that affects all celllines—perhaps an infection with fever and bloody diarrheaas well.” With clinical experience, these “networks ofdetailed, causal, pathophysiologic knowledge becomeencapsulated into diagnostic labels.that explain signsand symptoms.”5 At this stage, the learner may reason,“This child has infectious diarrhea that has lead to a sec-ondary process affecting the kidneys (anuric renal failure),the red blood cells (hemolytic anemia), and the platelets(thrombocytopenia).”

In early clinical reasoning, it is important to note thatlearners are also likely to be less developed in other com-petencies of patient care, such as gathering essential andaccurate information about the patient in the history andperforming complete and accurate physical examinations.Therefore, learners may not successfully elicit salient fea-tures of the clinical presentation and/or may give undueweight to features that are not as important, leading to sub-optimal clinical reasoning that can include diagnostic andtherapeutic considerations that are unnecessary and/orexclude considerations that are important.

INTERMEDIATE CLINICAL REASONING: THE EMERGENCE OF

ILLNESS SCRIPTS

With even further clinical experience, learners organizeknowledge as illness scripts or narrative scripts in whichthe characteristic features of specific illnesses form clinicalpatterns in memory.5,6 At this stage, the learner arrives atthe diagnosis of hemolytic uremic syndrome throughmatching the patient’s clinical picture to his illness scriptfor this disease, which may include elements of renal fail-ure (anuria, elevated creatinine, edema), hemolytic anemia(low hemoglobin, high LDH, pallor, tachycardia), throm-bocytopenia, and other features (eg, bloody diarrhea, a his-tory of eating a hamburger at the state fair, ill appearance,decreased energy and playfulness, irritability, and a myriadof other clinician-specific components). These illnessscripts can be used to compare and contrast diagnostic pos-sibilities by comparing clinical patterns of disease presen-tations. Clinicians continue to refine and remodel thesescripts as they encounter new patients. Over time, theybecome robust representations of diseases, each oneriddled with nuances and discriminating features of ill-nesses that even become context dependent.5 Episodicmemories of individual patients seen in the past add spe-cific situational information to these scripts, transformingillness scripts into “instance scripts” unique to individualpatients (eg, the 1-year-old with diabetes insipidus whodunked his head under the bath water and gulped wateras quickly as possible).6

ADVANCED CLINICAL REASONING: AVOIDING PREMATURE

CLOSURE

With advanced clinical experience, the knowledge struc-tures formed previously in the development of clinicalreasoning “do not decay; neither do they become inert,nor inaccessible. They sediment into multiple ‘layers’

which are accessed”1 in future clinical presentations whereillness scripts or instance scripts stored in memory cannotbe readily matched to a new patient who presents a diag-nostic and/or therapeutic dilemma.6 With this in mind, itis important to note that advanced clinicians are not just us-ing pattern recognition from previous cases they have seen.They are also engaging in analytic reasoning and usingtheir understanding of the underlying causal mechanismsof diseases and their pathophysiologic consequences tocompare and contrast the discriminating features of the di-agnoses they are entertaining.1,2,4 This mental activityavoids premature closure or settling on an incorrect diag-nosis based on cases in the past that looked similar onthe surface but were different upon deeper probing—aproblem that would persist if the clinician were usingpure pattern recognition.2

PROBLEM REPRESENTATION AND SEMANTIC QUALIFIERS

In this developmental progression, the sophisticationwith which medical knowledge in memory is organizedand made available for use in diagnostic and therapeuticreasoning is ever improving, a key determinant to theincreasing success of clinical judgment.9,12–16 Storageof knowledge and the retrieval of that knowledge, ratherthan the amount of knowledge, is related to diagnosticreasoning performance.17 For example, possessing ahigh level of knowledge that is poorly organized is asso-ciated with inadequate accessibility of diagnostic con-siderations and suboptimal diagnostic reasoning. It ishere again that the role of experience is important.With increased clinical experience, learners begin toreorganize clinical information that is gathered fromthe patient into abstract terms in their minds that theycan then use to categorize and understand clinical pre-sentations, “facilitat[ing] the retrieval of pertinent infor-mation from memory”4 and making it available fordiagnostic reasoning. This process is known as “problemrepresentation.”4,7 As part of this process, learners beginto use semantic qualifiers in their abstraction anddescription of cases.4,8

Semantic qualifiers are qualitative modifiers that givedeeper meaning to clinical information in the learner’smind and subsequently help learners discriminate clin-ical features and diagnostic hypotheses with more preci-sion and accuracy. They are most often described aspaired opposites that are used to describe clinical infor-mation (eg, acute and chronic; focal and diffuse; prox-imal and distal). However, they also includepathognomonic findings (eg, opsoclonus-myoclonus inneuroblastoma), criteria that are essential to make adiagnosis (eg, the triad of hemolytic anemia, thrombocy-topenia, and acute renal injury in the diagnosis of hemo-lytic uremic syndrome or the presence of 4 of 5 clinicalfeatures in addition to high fever to confirm the diag-nosis of typical Kawasaki disease), and absolute criteriafor exclusion of a diagnosis (eg, focal seizure excludingthe diagnosis of simple febrile seizure). As use of se-mantic qualifiers allows enhanced discrimination be-tween diagnoses, increasing use of semantic qualifiersis associated with increasing success in diagnostic


reasoning.8 As learners begin to use problem representa-tion and semantic qualifiers, the 2-year-old with “a tem-perature to 103�F and really bad ear pain on the left andright that began last night” becomes the “febrile (oppo-site of afebrile) toddler with acute (opposite of chronic)onset of severe (opposite of minor) bilateral (opposite ofunilateral) ear pain.” Through this abstraction and reor-ganization, this clinical knowledge is reframed in thelearner’s mind in a manner that facilitates the ready ac-cess to connect to and build upon previous knowledgefor use in diagnostic and therapeutic reasoning.

EVOLUTION OF CREATING A WORKING DIFFERENTIAL AND

SUBSEQUENT DECISION MAKING

In the developmental progression of diagnostic andtherapeutic reasoning, it is also helpful to consider theevolution of creating a working differential diagnosisand subsequent therapeutic decision making.2 Novicelearners, who do not possess knowledge specific to pedi-atrics, struggle to create diagnostic hypotheses for pedi-atric diseases. As a result, their early diagnostichypotheses tend not to change as more clinical informa-tion is gathered (because this new information is nothelpful in diagnostic and therapeutic reasoning). Inter-mediate learners tend to change their diagnostic hypoth-eses frequently as more information becomes available,often changing their diagnostic schema after the history,after the physical examination, after initial testing, andafter initial therapy and management. Their resultanttherapies tend to treat the features of a diagnosis ratherthan a unified diagnosis. Interestingly, the changing ofdiagnostic hypotheses for novice and perhaps for inter-mediate learners may depend on the type of additionalclinical information provided. The work of Coderreand colleagues18 demonstrates that first-year medicalstudents are much less likely to retain their initial diag-nostic hypothesis when additional information is discor-dant with initial information, whereas they are muchmore likely to retain their initial diagnostic hypothesiswhen subsequent information is concordant. Advancedlearners tend to develop quite advanced and narroweddiagnostic hypotheses early in a case and use subsequenthistory, physical examination, and tests to confirm thisinitial schema. As a result, their therapies tend to befocused and specific, based on a unifying diagnosis forthe patient.


� Presents history and physical examination in the order they wereelicited without filtering, reorganization, or synthesis. Presents a listof all diagnoses considered rather than a focused set of workingdiagnostic hypotheses. Limited development of a diagnostic andtherapeutic plan.

� Focuses on features of the clinical presentation, making a unifyingdiagnosis elusive and leading to a continual search for newdiagnostic possibilities. Presents several tests and therapies ratherthan a focused set of working diagnostic hypotheses. Develops adiagnostic and therapeutic plan that is not clear, organized, and/orwell aligned with a prioritized differential diagnosis.

� Uses semantic qualifiers (such as paired opposites that are used todescribe clinical information [eg, acute and chronic]) to compareand contrast diagnoses being considered. Presents a focused setof working diagnostic hypotheses. Develops diagnostic andtherapeutic plans that are well synthesized and organized around afocused differential diagnosis.

� Demonstrates the ability to initiate and articulate earlydirected hypothesis testing and confirm these hypotheseswith subsequent history, physical examination, and diagnostictests. Identifies discriminating features between similarpatients and avoids premature closure. Presentations focuson tailored therapies based on a unifying diagnosis. Developsdiagnostic and therapeutic plans focused on an effective andefficient diagnostic workup tailored to address individualpatients.

� Current literature does not distinguish between behaviors ofproficient and expert practitioners. Expertise is not anexpectation of GME training, as it requires deliberate practiceover time.

REFERENCES

1. Schmidt HG, Boshuizen HPA. On acquiring expertise in medicine.

Educ Psychol Rev. 1993;5:205–221.

2. Patel VL, Groen GJ, Patel YC. Cognitive aspects of clinical perfor-

mance during patient workup: the role of medical expertise. Adv

Heatlh Sci Educ. 1997;2:95–114.

3. Bordage G. Elaborated knowledge: a key to successful diagnostic

thinking. Acad Med. 1994;69:883–885.

4. Bowen JL. Educational strategies to promote clinical diagnostic

reasoning. N Engl J Med. 2006;355:2217–2225.

5. Schmidt HG, Rikers RMJP. How expertise develops in medicine:

knowledge encapsulation and illness script formation. Med Educ.

2007;41:1133–1139.

6. Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on

medical expertise: theory and implications. Acad Med. 1990;65:

611–621.

7. Chang RW, Bordage G, Connell KJ. The importance of early problem

representation during case presentations. Acad Med. 1998;73:

S109–S111.

8. Bordage G. Prototypes and semantic qualifiers: from past to present.

Med Educ. 2007;41:1117–1121.

9. Coderre S, Mandin H, Harasym PH, Fick GH. Diagnostic

reasoning strategies and diagnostic success. Med Educ. 2003;37:

695–703.

10. KolbDA.Experiential Learning: Experience as the Source of Learning

and Development. Upper Saddle River, NJ: Prentice-Hall; 1983.

11. Bereiter C, Scardemalia M. Surpassing Ourselves: An Inquiry Into

the Nature and Implications of Expertise. Chicago, Ill: Open Court;

1993.

12. Bordage G, Grant J, Marsden P. Quantitative assessment of diagnostic

ability. Med Educ. 1990;24:413–425.

13. Gale J, Marseden P. Clinical problem-solving: the beginning of the

process. Med Educ. 1982;16:22–26.

14. Gale J, Marseden P. Medical Diagnosis: From Student to Clinician.

Oxford, UK: Oxford University Press; 1983.

15. Gale J, Marseden P. Role of the routine clinical history. Med Educ.

1984;18:96–100.

16. Grant J, Marsden P. The structure of memorized knowledge in stu-

dents and clinicians: an explanation for diagnostic expertise. Med

Educ. 1987;21:92–98.

17. Bordage G, Lemieux M. Semantic structures and diagnostic thinking

of experts and novices. Acad Med. 1991;66:S70–S72.

18. Coderre S, Wright B, McLaughlin K. To think is good: querying an

initial hypothesis reduces diagnostic error in medical students. Acad

Med. 2010;85:1125–1129.














































Competency 7. Develop and carry out management plans

Robert Englander, MD, MPH

BACKGROUND: This competency is intimately enmeshedwith other competencies and domains of competencedescribed in this document. It is perhaps most intimatelylinked to competency 6: “Make informed diagnostic andtherapeutic decisions that result in optimal clinical judg-ment.” Much of the literature refers to “making informeddiagnostic and therapeutic decisions” and “developingmanagement plans” with one voice,1–3 often under therubric of clinical judgment. The literature on illness scriptsis particularly pertinent and has been covered in the “Makeinformed diagnostic and therapeutic decisions.” compe-tency.

Nilsson and Pilhammar4 provide an additional frame-work for understanding the developmental progression inclinical judgment through a qualitative analysis of juniorand senior physicians using a critical incident technique.They found that junior and senior physicians demonstrateddifferences in clinical judgment in a number of differentareas, including those that follow.

USE OF THEORETICAL KNOWLEDGE VERSUS USE OF PREVIOUS

EXPERIENCE AND KNOWLEDGE OF THE COURSE OF EVENTS

Junior physicians tend to base their clinical judg-ments and management plans predominantly on theirtheoretical knowledge. As one matures, one hasincreasing superimposition of experience to place thetheoretical knowledge in context toward an understand-ing of issues such as risk and prognosis. The mostseasoned clinician can build upon theoretical knowledgewith experience in ever more complicated and difficultsituations.

ETHICAL APPROACH TO MANAGEMENT DECISIONS

Junior physicians tend to exercise clinical judgmentfounded on their own personal assumptions of how oneshould behave in general and in consideration of healthcare resources. The senior practitioner is increasinglyable to understand individual patients in the context of theirlives to make decisions that maximize well-being, mini-mize harm, and avoid overtreating.

MEETING AND COMMUNICATING WITH PATIENTS

Junior physicians tend toward 1-way communication ofinformation to patients. Senior physicians become increas-ingly engaged in 2-way discussions around management.The most experienced clinicians are also aware of howtheir own biases, needs, and behavior play into the commu-nication with patients around clinical judgment.

FOCUSING ON AVAILABLE INFORMATION

The most inexperienced clinician will be unable to siftthrough the information available to come to the key ele-ments. As a result, clinical judgment is often based on a

relatively arbitrary and poorly prioritized sampling of theinformation and is limited by the time available. Withincreasing experience, one is able to focus on key elementsof information early and then augment from the remainingsources of information as necessary. An example might bea patient with multiple medical problems who comes for ahealth supervision visit to the outpatient setting. The inex-perienced clinician will be unable to navigate the longmedical record in a meaningful way in the time allotted, re-sulting in less than optimal use of the time to plan patientmanagement. The experienced clinician, conversely, willzero in on the key information from the medical recordin the time allotted, before entering the examinationroom, allowing optimal use of time to plan care.

BEING DIRECTED BY THE ORGANIZATION

Junior physicians note that they often develop manage-ment plans according to perceived or real health care orga-nization directives (eg, “The Joint Commission makes medo this”) without an understanding of the rationale orimportance to the patient. Of note, senior clinicians donot cite this as an issue for them in clinical judgment,even though they follow the organizational guidelines.For them, directives become a matter of habit and formthe basis, rather than the entirety, of the discussion aroundmanagement.These differences inform the milestones outlined below

and aid in creating a picture of the continuum of compe-tency in developing and carrying out management plans.


� Develops and carries out management plans based on directivesfrom others, either from the health care organization or thesupervising physician. Unable to adjust plans based on individualpatient differences or preferences. Communication about the planis unidirectional from the practitioner to the patient and family.

� Develops and carries out management plans based on one’stheoretical knowledge and/or directives from others. Can adaptplans to the individual patient, but only within the framework ofone’s own theoretical knowledge. Unable to focus on keyinformation, so conclusions are often from arbitrary, poorlyprioritized, and time-limited information gathering. Managementplans based on the framework of one’s own assumptions andvalues.

� Develops and carries out management plans based on boththeoretical knowledge and some experience, especially inmanaging common problems. Follows health care institutiondirectives as a matter of habit and good practice rather than as anexternally imposed sanction. Focuses on key information, but stillmay be limited by time and convenience. Plans begin to incorporatepatients’ assumptions and values through more bidirectionalcommunication.

� Develops and carries out management plans based most often onexperience. Efficiently focuses on key information to arrive at a plan.Incorporates patients’ assumptions and values throughbidirectional communication with little interference from personalbiases.

Delta:1_surname


� Develops and carries out management plans, even forcomplicated or rare situations, based primarily on experiencethat puts theoretical knowledge into context. Rapidly focuseson key information to arrive at the plan and augments thatwith available information or seeks new information asneeded. Has insight into one’s own assumptions and valuesthat allow one to filter them out and focus on the patient/family values in a bidirectional conversation about themanagement plan.

REFERENCES

1. Charlin B, Boshuizen HP, Custers EJ, Feltovich PJ. Scripts and clinical

reasoning. Med Educ. 2007;41:1178–1184.

2. Norman G, Young M, Brooks L. Non-analytical models of clinical

reasoning: the role of experience. Med Educ. 2007;41:1140–1145.

3. Schmidt HG, Rikers RM.How expertise develops inmedicine: knowledge

encapsulation and illness script formation.MedEduc. 2007;41:1133–1139.

4. Nilsson MS, Pilhammar E. Professional approaches in clinical judg-

ments among senior and junior doctors: implications for medical edu-

cation. BMC Med Educ. 2009;9:25.

Competency 8. Prescribe and perform all medical procedures

Patricia Hicks, MD, MHPE

BACKGROUND: All of the competencies are involved inprescribing and performing medical procedures. In an inte-grated fashion, development of elements of competence inthe performance of procedures takes place along a contin-uum, with ongoing deliberate practice required to achieveand sustain competence.

Prescribing medical procedures is a process that in-cludes the ability to weigh many factors to achievethe optimal outcome for an individual patient. Prescrib-ing medical procedures requires careful considerationof the indications, contraindications, benefits, risks,anticipated undesirable outcomes, and complications,all within the specific anatomic and physiologic stateof a specific patient’s condition. Consideration of thesemany factors and their complex interplay results indetermining the best short- and long-term therapeuticoutcome. Awareness and appreciation of unintended,but known, consequences or risks is part of the deci-sion-making process, as well as the postprocedure man-agement process. The prescribing process as part ofprocedural competency involves other competencies,such as diagnostic reasoning, clinical decision making,and communication; informed consent is a related butseparate area of competence embedded within theachievement of performance of medical procedures.The prescribing process may be undertaken for the pur-pose of achieving an immediate, desirable, therapeuticoutcome as the primary goal (eg, bladder catheteriza-tion for a neurogenic bladder or suturing of a lacera-tion), or the procedure might be prescribed as abeneficial means to an end (eg, obtaining evidence inthe form of laboratory data or providing access toadminister medications into a vein). Thus, developingcompetence in prescribing and performing proceduresinvolves cognitive and communication skills as wellas psychomotor skills.

The problem of assessing competence in the perfor-mance of procedures has been reported for over 2 de-cades. In 1989, Wigton et al1 surveyed 2500 generalinternists and reported that newer graduates were per-forming more and more procedures. However, a surveyof internal medicine training program directors conduct-ed at the same time reported that while 53% had devel-

oped a list of procedural skills that all their residentsmust master, only 21% had developed specific criteriafor competence in procedural skills. Fifty-six percentof the 389 program directors surveyed stated that theyplanned to develop criteria for competence in proceduralskills. Eighty-two percent stated that a “uniform systemto be used by all programs to document procedureswould be helpful.”2 Today, there is still not a uniformsystem for demonstrating graduate competence in proce-dural skills.In 1992, responders to a survey of internal medicine

graduates reported that they had not mastered the proce-dures that their program directors thought they should mas-ter. Their program directors had approved privileges forthese procedures on credentialing applications, allowingthose graduates to perform those procedures without super-vision. Many of the survey’s responding graduates reportedlearning procedures without supervision, often after theyentered practice.3

Confidence, or operator comfort with performance ofprocedures, has not been shown to be a useful proxy inproviding evidence of competence of performance of pro-cedures.4 The popularity of evaluating curriculum at Kirk-patrick’s lowest stage,5,6 which is learner satisfaction, hasbeen addressed by Kirkpatrick in the following judgment:“Evaluating reaction is the same thing as measuringcustomer satisfaction.”6 Enjoying simulation training ses-sions and leaving those sessions with a great confidence,comfort, or satisfaction may not necessarily equate tocompetence in performing those procedures. Just as thephysician’s ability to self-assess his cognitive skills is oftenflawed, so is self-assessment of procedural competence.7

Some examples follow.Carbine et al8 videotaped individuals providing neonatal

resuscitation to compare the resuscitation methods appliedagainst the standards set forth by the Neonatal Resuscita-tion Program (NRP). Their group found a “significant num-ber of deviations from the NRP guidelines”8 demonstratedon video recordings; 30% of NRP steps were not performedor were performed incorrectly despite having completedNRP training.Adams et al9 reported that despite going through NRP

training, residents were less successful at intubation on










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Table 2. Assessments by Procedure and Along a Developmental Continuum

Competency in Performance

of Specified Procedure*

Early Learner / Developmentally Advanced Learner

Cognitive Knowledge Related to Procedures: Knowledge and Clinical Application of KnowledgeProcedural

Motor Skills

Postprocedure

Management

Group

No.

Required

Procedures

Optional

Procedures§

Anatomy

and

Physiology

Indications

and Benefits

Contraindications

and Risks

Informed

Consent

Pain Management;

Patient

Psychological

Preparation

Specimen

Handling

Interpretation

of Results†

Checklist-Driven

Task Analysis

Anticipation,

Monitoring,

Assessment‡

1 Lumbarpuncture

X X X X X X X Operator X

3 Umbilical arterialcatheter placement

X X X .jj X X X Assistant X

1 Suturing of scalp X X X X X X X Operator X2 Suturing laceration

across lip borderX X X .jj X NA X Assistant NA

3 Thoracentesis X X X .jj X X NA X

NA indicates not applicable.

*Includes indications, contraindications, complications, limitations, interpretation of findings, and technical (psychomotor) skills.

†Interpretation of laboratory findings of specimens, postprocedure radiographic images, therapeutic changes, and so on.

‡Anticipates complications andmanages those complications; performs ongoingmonitoring and assessment of patient with escalation of care as needed; provides communication of statuswith family and

care team.

§These additional procedural skills may be pursued if the residents’ practice expectations indicate a use for such skills and if and only if the training environment is able to provide such training (includes

availability of skilled teaching faculty15). It is beyond the scope of thesemilestones to propose pediatric program requirements and the examples here are listed simply as examples of possible procedures by

category.

jjInformed consent elements may be known, but the actual informed consent must take place by the primary operator for the procedure.

S26

PATIENTCARE

ACADEMIC

PEDIATRICS

Table 3. Developmental Spectrum of Elements of Competency on Prescribing and Performance of Procedures

Element Beginning of Spectrum Below Mean Above Mean Verification of Training Complete

Anatomy andPhysiology;Indicationsand Benefits;Contraindicationsand Risks

2 SD belowmean on knowledgetest

1 SD below mean onknowledge test

1 SD abovemean onknowledge test

2 SD above mean on knowledgetest

Informed Consent16 Informed consent represents aprocess limited to obtaining asignature; limited knowledgeof elements of informedconsent restricted; dialoguewith family/patient results inlow information exchange.The signed documentbecomes the desiredoutcome, rather thanachieving the patient/familyunderstanding of the requisitediscussion for true informedconsent.

Informed consent takes place aspart of a continuous dialogue,beginning before the decisionto perform the procedure andcontinuing after the procedureis completed. Elements of theinformed consent arepresented in comprehensivefashion, with open opportunityto question and consideroptions. True understandingand agreement are measuredby the parent or patient’s abilityto teach back key elements ofrisks, benefits, and options.

Pain Management,Patient PsychologicalPreparation

Pain management is notdiscussed. Consideration ofease or efficiency ofprocedure takes precedenceover family adjustment to orreadiness for the procedure.

Consideration for and anticipationof psychological and physicalpain associated with procedureor preparation for procedure isundertaken by multidisciplinaryteam, when indicated.Coordination of team is eithermanaged by the operator ordelegated to others, with directinvolvement of the operator.

Specimen Handling Little understanding of howsamples should be handled,resulting in need to repeatprocedure or suboptimalresults/interpretation.

1 SD below mean onknowledge test

1 SD abovemean onknowledge test

Preprocedure planning withidentification of neededstudies. Contact made withspecial laboratories to assurethat the samples can betransported and analyzedproperly; scheduling ofprocedure is done with regardto special transporting,storage, or testing issues aswell as patient preferences.

Interpretation ofResults or Outcomes

Understanding results is limitedto reading of a report; inabilityto determine what resultsmean in the context of thepatient’s clinical condition;“normal” and “abnormal” aretaken at face value withoutunderstanding of truemeaning; analyticalinformation about testspecificity, sensitivity andconfounding factors are notutilized.

Demonstrates consideration ofpatient age and thephysiological conditions underwhich the results were obtainedwith consideration of baselinepatient status, diseaseprocess, validity of evidence/results, coexisting conditions,and other confounders.

(Continued )


Table 3. Continued

Element Beginning of Spectrum Below Mean Above Mean Verification of Training Complete

ProceduralTechnique

2 SD below mean on procedureperformance, as measuredby a standardized checklist,standardized simulationassessment, or otherassessment method provento have high-validityevidence. Hierarchical taskanalysis (the assessment ofeach step in the sequence ofa psychomotor task)17,18 isused to rate individualelements as well as measurefluidity and states such assituational awareness andcourse correction.

1 SD below mean 1 SD above mean 2 SD above mean

PostprocedureManagement

No patient follow-up afterprocedure or only follows upon assigned tasks (eg,checking an x-ray). Littleknowledge and clinicalunderstanding of anticipatedand undesirable outcomes[on direct testing]; ifescalation is needed(unanticipated), does notrecognize; when questioned,does not identify potentialadverse outcomes.

Follows clearly outlined protocolfor postproceduremanagement, adjusting thecare plan as needed to respondto patient-specific outcomes.Identifies unexpected patientcare status changes or eventsafter procedure andcommunicates an appropriatelevel of uncertainty, seekingresources in an escalatingmanner until resolution.Communicates with patient,family, and care team aboutsuch uncertainty in a fashionthat is transparent andinformative.


the first attempt than respiratory therapists on a transportteam.

Eighty-seven percent of pediatric residents in training ina study by Falck et al10 reported confidence in their abilityto intubate neonates. Yet 35% of the intubation attemptswere never successful by the pediatric house officers inthat study. These individuals were surveyed after gradua-tion, and 71% of the group’s respondents stated that theywere practicing general pediatrics and 36% were attendingdeliveries.

There is abundant evidence that counting proceduresalone is not adequate evidence of competence. Colliveret al11 conducted a study comparing the number of proce-dures performed to performance of those procedures usinga gold-standard competency assessment model of simula-tion and animal models. His work demonstrated that thenumber of procedures needed to demonstrate competencefar exceeded the number recommended by most residencyprograms.

Last, the particular group of procedures a pediatricianwishes to perform without direct supervision dependslargely on their individual career goals. Jones andMcGuin-ness12 have described an educational approach that con-siders this differentiation. For the majority of proceduresin pediatrics, the pediatrician may prescribe and managethe patient, but may not directly perform many procedures.

A relatively short, select list of procedures has beendeemed by the American Board of Internal Medicine(ABIM) as appropriate for generalists to perform withoutdirect supervision.13 It is anticipated that a finite group ofprocedures will be recommended for a categorical pediat-ric resident who anticipates hospital privileges as a generalpediatrician; deliberate training for this subset of proce-dures is anticipated. Thus, the categorical general pediatricgraduate would seek to be competent in the cognitive andpsychomotor components of a select group of procedures,have awareness of these components for another group ofprocedures, and the ability to assist in yet another groupof procedures.With competence, performing any procedure without

ongoing deliberate practice results in extinction or attenua-tion of skills. Likewise, deliberate practice is required toachieve more highly reliable functioning associated withproficiency andmastery. There are no data to address the in-tervals recommended for reassessment or retraining in pro-cedural competence, but there is evidence that currentintervals may be inadequate.14 Therefore, ongoing reas-sessment will need to be part of continuing professionaldevelopment such as maintenance of certification, mainte-nance of licensure, or the granting of hospital privileges,and relate directly to the type of practice (and thereforethe type of procedures encountered or performed) (Table 2).


DEVELOPMENTAL MILESTONES:The component knowledge, skills, and attitude of eachprocedure are numerous and complex. They include:

� Anatomy and physiology.� Indications and benefits.� Contraindications and risks.� Informed consent.� Pain management, patient psychological preparation.� Specimen handling.� Interpretation of results or outcomes.� Procedural technique (multiple elements unique to pro-

cedure; common elements to all [eg, sterile technique,situational awareness, course correction]).

� Postprocedure management.

This approach to assessment makes some assumptions:� Performance level is specific to each procedure based on

the relevant components and level of responsibility ofthe physician.

� Given the variability of required components, measuresof competence are based on all of the relevant compo-nents for that procedure.

� Performance level for a given procedure therefore re-quires reaching the desired performance level for eachof the individual components.The developmental progression is outlined in Table 3.

REFERENCES

1. Wigton R, Nicolas J, Blank L. Procedural skills of the general inter-

nist: a survey of 2500 physicians. Ann Intern Med. 1989;111:

1023–1034.

2. Wigton R, Blank L, Nicolas J, Tape T. Procedural skills training in in-

ternal medicine residencies. Ann Intern Med. 1989;111:932–938.

3. Wigton R. Training internists in procedural skills. Ann Intern Med.

1992;116:1091–1093.

4. Hicks C, Gonzales R, Morton M, et al. Procedural experience and

comfort level in internal medicine trainees. Gen Intern Med. 2000;

15:716–722.

5. Kirkpatrick DL. Evaluating Training Programs: The Four Levels. San

Francisco, Calif: Berrett-Koehler; 1998.

6. Kirkpatrick L, Kirkpatrick JD. The four levels: an overview. In:

Kirkpatrick DL, ed. Evaluating Training Programs: The Four Levels.

San Francisco, Calif: Berrett-Koehler; 2006:21–26.

7. Davis D. Accuracy of physician self-assessment compared with

observed measures of competence. JAMA. 2006;296:1094–1102.

8. Carbine D, Finer N, Knodel E, RichW. Video recording as a means of

evaluating neonatal resuscitation performance. Pediatrics. 2000;106:

654–658.

9. Adams K, Scott R, Perkin R, Langga L. Comparison of intubation

skills between interfacility transport team members. Pediatr Emerg

Care. 2000;16:5–8.

10. Falck A, Escobedo M, Baillargeon J, et al. Proficiency of pediatric

residents in performing neonatal endotracheal intubation. Pediatrics.

2003;112:1242–1247.

11. Colliver J, Vu N, Barrows H. Screening test length for sequen-

tial testing with a standardized-patient examination: a receiver

operating characteristic (ROC) analysis. Acad Med. 1992;67:

592–595.

12. Jones D,McGuinness G. The future for pediatric residency education:

the prescription for more flexibility. J Pediatr. 2009;154:157–158.

13. American Board of Internal Medicine. Internal medicine policies.

Available at: http://www.abim.org/certification/policies/imss/im.

aspx?print#procedures. Accessed September 13, 2013.

14. Kovacs G, Bullock G, Ackroyd-Stolarz S, et al. A randomized

controlled trial on the effect of educational interventions in promoting

airway management skill maintenance. Ann Emerg Med. 2000;36:

301–309.

15. Wickstrom GC, Kelley DK, Keyserling TC, et al. Confidence of aca-

demic generalist internists and family physicians to teach ambulatory

procedures. J Gen Intern Med. 2000;15:353–360.

16. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed.

New York, NY: Oxford University Press; 2001.

17. Sarker S, Chang A, Albrani T, Vincent C. Constructing hierarchical

task analysis in surgery. Surg Endosc. 2008;22:107–111.

18. Shepherd A. HTA as a framework for task analysis. Ergonomics.

1998;41:1537–1552.

Competency 9. Counsel patients and families

Susan Guralnick, MD

BACKGROUND: Counseling of patients and families shouldbe patient centered, requiring the practitioner to “meet thepatient’s/family’s need for obtaining information about thedisease, providing guidance and solving problems collabo-ratively, all of which are aimed at helping the patient to bet-ter manage the health problem.”1 The practitioner’s level ofknowledge and self-confidence about a specific topic arekey components of how well she will counsel patients.Essential to effective counseling is clarification of thedesired outcome. The ideal approach balances the“discrepancy between the best possible care and the inev-itable compromises in adapting management to the real pa-tient’s circumstances.”1 For example, in the case of anasthma patient with frequent exacerbations, the practi-tioner must first determine whether the patient is takingthe prescribed controller medications. If the patient isnot, the practitioner must identify the reason or reasons

for this nonadherence. There are many reasons why thismay have occurred, including patient/family misunder-standing, inadequate resources, living conditions, or signif-icant family issues that impede following the prescribedregimen. The practitioner will be unable to help the pa-tient/family develop a plan for behavior change withoutan assessment of the patient/family situation and a behav-ioral management plan that takes the context of the pa-tient’s/family’s lives into account.The method of appreciative inquiry, in which the clini-

cian “engages in a dialogue that draws out, builds on, andreinforces stories of what the [patient/family] feels worksor has worked in his or her life, affirming [the patient/fam-ily’s ability] to make decisions”2 can be effectivelyapplied here. Appreciative inquiry was defined in the1980s as a “method of organizational development inwhich the ‘best of what is’ is made better.”2 Medical

































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http://www.abim.org/certification/policies/imss/im.aspx%3Fprint#procedures














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practitioners have begun to successfully apply thisapproach to patient counseling. As applied to the asthmacase above, the practitioner would engage the patient/family in a discussion of past successful behaviors.Through this process, they discover that in the past the pa-tient has been most successful in completing prescribedmedication courses when he consistently takes the medi-cine before bedtime or at mealtime, using a temporal cueas a reminder. A plan would then be developed using atemporal association to improve controller medicationadherence.

Independent of the method, physicians must developskills in each step of the counseling interaction. As definedin the literature, the critical steps of counseling includedetermining the magnitude of the problem, stronglyencouraging behavior change, determining the patient’swillingness to change, and helping the patient change thebehavior.3 In order to accomplish this, there must be useof language that is clear and understandable, open discus-sion, movement away from authoritarian recommenda-tions to shared decision making, and empathy for thepatient’s circumstances, goals, values, and culture.


� Responds to patient’s/family’s questions without an adequateknowledge base, and does not initiate discussion of healthy behaviorchange. The conversation contains frequent medical jargon anddisplays personal biases. Does not demonstrate consideration ofpatient’s specific circumstances. No plan for change is discussed.

� Recommends healthy behavior change, but provides littleopportunity for discussion or questions. The conversation containsfrequent medical jargon and may display personal biases. Showslittle empathy/adaptation for patient’s specific circumstances.Defines a plan for the patient.

� Encourages healthy behavior change and answers the patient’s/family’s questions. Listens to the patient/family andbegins to expresscaring, concern, and empathy. Maintains a respectful tone and rarelyusesmedical jargon. Incompletely or inconsistently assesses patient/family understanding. Superficially addresses the patient’s options.Demonstrates recognition that patients have varying circumstancesand begins to involve patient/family in developing a plan.

� Promotes healthy behavior change. Encourages the patient/family toask questions. Uses active listening and expresses caring, concern,and empathy. Maintains a respectful tone and avoidsmedical jargon.Checks the accuracy of the patient’s/family’s understanding.Explains choices in light of patient’s circumstances, goals, values,and culture. Acknowledges the patient’s/family’s accomplishments,progress, and challenges and negotiates mutually acceptable plans.

� Partners with the patient/family to achieve healthy behavior change.Encourages the patient/family to ask questions. Uses activelistening and expresses caring, concern, and empathy. Maintains arespectful tone and avoids medical jargon. Identifies the patient’s/family’s strengths through appreciative inquiry and builds on them.Engages in shared-decision making with the patient/family todevelop plans for change that are realistic and achievable within thecontext of their lives and assesses the accuracy of the patient’s/family’s understanding.

REFERENCES

1. Benbasset J, Baumal R. A step-wise role playing approach to teaching

patient counseling skills to medical students. Patient Educ Couns.

2002;46:147–152.

2. Moore SM, Charvat J. Promoting health behavior change using

appreciative inquiry: moving from deficit models to affirmation

models of care. Family Community Health. 2007;30(1 suppl):

S67–S77.

3. Lee MT, Hishinuma ES, Derauf CD, et al. Smoking cessation coun-

seling training for pediatric residents in the continuity clinic setting.

Ambul Pediatr. 2004;4:289–294.

Competency 10. Provide effective health maintenance and anticipatory guidance

Susan Guralnick, MD

BACKGROUND: Health maintenance and anticipatory guid- cian attitude, knowledge, and comfort.3,4 Another key factor
ance are fundamental to pediatric practice. Up to two-thirdsof pediatric office visits are for well child care, and a greatportion of each well-child care visit is spent addressingbehavior, development, immunizations, nutrition, and injuryprevention.1 Many of these issues are attended to duringacute care visits as well. It is therefore essential that pediatri-cians be trained to provide appropriate health maintenanceand anticipatory guidance. “Anticipatory guidance consistsof the information that clinicians give families about whatthey should expect in their child’s development, what theyshould do to promote this development, and the benefits ofthese healthy lifestyles and practices. It is distinct fromcoun-seling, which is advice given in response to specific prob-lems.”2 Anticipatory guidance can be offered in manyforms, including personal discussion, written information,video, and via the Internet.2 There are several tools availablethat provide a systematic approach to this process.While it isclear that this is an important skill, evidence shows that physi-cian performance in this realm is highly dependent on physi-
is “confidence in their ability to motivate behavior change.”4

The pediatricianmust bepreparedandwilling to offer age-specific anticipatory guidance ranging from choking preven-tion in a toddler to drug and alcohol use prevention in anadolescent. The practitioner must be ready and available towork with the family to enable lifestyle and practice changewith consideration of the family-specific situation. Beyondthe basics of knowledge, skills, and attitudes, the practitionerhas a lifelong responsibility to remain up to datewith currentguidelines and resources available for health maintenance.The medical education experience in the United States isoften not ideallydesigned toprepare physicians aspreventivemedicine practitioners, emphasizing the diagnosis and treat-ment of disease over preventive care. Thus, many practi-tioners are not well equipped at the time of graduationfrom residency to provide the preventive care that is requiredin practice.3 Knowledge of the precepts of health mainte-nance, the use of appropriate screening procedures, movingfrom external to internal prompts for offering anticipatory











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guidance, and the ability to elicit and address unhealthy be-haviors are the core elements necessary for competence inthis domain. Opportunities to develop these skills must beprovided and nurtured during training in order to developthe habit of emphasizing preventive care in practice.


� Demonstrates little familiarity with health maintenance concepts (eg,recommending exercise, nutritional assessment). Performs age-appropriate screening procedures only when instructed to do so.Answers patients’ and families’ questions without offeringanticipatory guidance.

� Demonstrates familiarity with, but has little knowledge of,health maintenance concepts. Uses resources made availableto her for health promotion and disease prevention, but doesnot seek new information or resources. Often performs age-appropriate screening procedures. Inconsistently offersanticipatory guidance without prompting. Inconsistentlyidentifies and addresses unhealthy behaviors during patient/family interactions.

� Demonstrates some knowledge of health maintenance concepts.Uses available resources and begins to seek new and currentresources, guidelines, and recommendations for health promotionand disease prevention. Usually performs age-appropriatescreening procedures and offers anticipatory guidance withoutprompting. Frequently identifies unhealthy behaviors duringpatient/family interactions and addresses those with the patient/family.

� Demonstrates knowledge about health maintenance concepts.Routinely identifies and accesses current best evidence-basedresources and recommendations for health promotion and diseaseprevention. Habitually performs age-appropriate screening andprovides anticipatory guidance. Characteristically communicatesinformationabout expectedbehavior, development, and safety needsas well as promoting a healthy lifestyle. Works with individual patientsand populations of patients to promote healthy behaviors, changeunhealthy behaviors, and enhanceadherence to improvedbehaviors.

� Assesses health maintenance or anticipatory guidance needs at alocal, regional, national, and global level andworks to address thoseneeds. Adapts health maintenance and anticipatory guidanceinteractions to the current and expected needs of patients andfamilies in the context of their cultural and personal circumstances.

REFERENCES

1. Lopreiato JO, Foulds DM, Littlefield JH. Does a health maintenance

curriculum for pediatric residents improve performance? Pediatrics.

2000;105:966–972.

2. Nelson CS, Wissow LS, Cheng TL. Effectiveness of anticipatory

guidance: recent developments. Curr Opin Pediatr. 2003;15:

630–635.

3. Cardozo LJ, Steinberg J, Lepczyk MB, et al. Improving preventive

health care in a medical resident practice. Arch Intern Med. 1998;

158:261–264.

4. Cheng TL, DeWitt TG, Savageau JA, O’Connor KG. Determinants of

counseling in primary care pediatric practice physician attitudes about

time, money, and health issues. Arch Pediatr Adolesc Med. 1999;153:

629–635.

Competency 11. Use information technology to optimize patient care.

This competency is combined with the competency 7(use information technology to optimize learning andcare delivery) of Practice-Based Learning and Improve-ment.1

REFERENCES

1. Burke AE, Benson B, Englander R, Carraccio C, Hicks PJ. Domain of

Competence: Practice-based learning and improvement. Acad Pediatr.

2014;14:S38–S54.

Competency 12. Provide appropriate role modeling

Susan Guralnick, MD

BACKGROUND: Role models play an essential role in char-acter and professional development. The Merriam-Webster Dictionary defines a role model as “a personwhose behavior in a particular role is imitated by others.”1

The term “role model” was coined by Dr. Robert K. Mer-ton, the pioneering sociologist, in his publication of a 5-year study of the socialization of medical students. Mer-ton theorized that individuals identify reference groupsto which they may or may not belong for purposes ofself-comparison. In addition, individuals identify socialgroups, each having a set of social roles that is associatedwith a specific set of behaviors, to help learn appropriatesocial roles.2 Merton’s work defines socialization as thelearning of those social roles. “Socialization takes placeprimarily through social interaction with people who are

significant for the individual. In its application to the med-ical student, socialization refers to the processes throughwhich he develops his professional self, with its charac-teristic values, attitudes, knowledge, and skills, fusingthese into a more or less consistent set of dispositionswhich govern his behavior in a wide variety of profes-sional (and extra-professional) situations.”3 Professionalsocialization refers to the aspect of socialization thatmust occur for an individual to be accepted into an occu-pational group; that is, he must “accept the common coreof relatively homogeneous values, norms, and role defini-tions of that group.”4

“Role models—people we can identify with, who havequalities we would like to have, and are in positions wewould like to reach—have been shown as a way to

















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inculcate professional values, attitudes, and behaviors instudents and young doctors.”5 Role modeling using bothpositive and negative examples is a core element in thetraining of physicians. Any interaction in any setting is ateaching opportunity—an opportunity to teach by example.“The informal curriculum, which consists of unscripted,unplanned, and highly interpersonal forms of teachingand learning” is a very powerful teaching tool for passingon the knowledge, skills, and values of the medical profes-sion.6

The skills and attributes of role modeling can be taughtand developed. Physicians must become aware of theimpact of their behaviors on others and begin to reflecton and articulate to learners what they are modeling “tomake the implicit explicit.”6 When shared with learners,reflection in action, the practice of analyzing one’s perfor-mance as it occurs, and reflection on action, which takesplace after the event, are extraordinary opportunities forrole modeling. Reflection in action occurs when encoun-tering a situation that is outside one’s experience orknowledge, leading the physician to immediately definethe problem and identify a solution. For example, anintern enters a room and encounters an angry family. Hemust act to diffuse the situation but may have little orno experience. He will have to evaluate the circumstancesand develop an immediate action plan based on informa-tion available and the dynamics in the room. In the nextstage of development, reflection on action, the physicianreflects on events after the fact, critically evaluating thesituation and seeking alternate and possibly better solu-tions for future encounters. Absent the active and sharedreflection, the passing on of these attributes to learnersmay not take place. “Awareness of being a role model,the conscious recognition of the importance of rolemodeling as a teaching and learning strategy, and the pos-itive or negative impact of what we are modeling, isfundamental to improving performance. We are rolemodels at all times.”6


� Performs routine duties and behaviors of profession withoutawareness of the impact on those around her. Does notdemonstrate evidence of reflection on actions as they occur(reflection in action) and does not share reflections with others.

� Demonstrates awareness of the impact of one’s behaviors andattitudes on others inconsistently. Sometimes teaches by example.Occasionally will reflect openly on events as they occur (reflection inaction) and demonstrates evidence of private reflection on eventsthat have already taken place (reflection on action) throughobservable behavior changes.

� Expresses consciousness of being a role model during manyinteractions. Frequently teaches by example and often reflects inaction openly in the presence of learners. Behavior implies frequentprivate reflection on action.

� Expresses consciousness of being a role model during mostinteractions. Routinely teaches by example. Regularly reflects inaction and frequently reflects on action, resulting in behaviorchanges and sharing of this analysis of practice with learners.

� Demonstrates evidence that role modeling is a continuous process.Expresses recognition that she is a role model in all actions andbehaviors at all times. Characteristically teaches by example.Routinely reflects both in action and on action. Examines, analyzes,and explains actions/behaviors in the presence of learners andcolleagues.

REFERENCES

1. Role model. Merriam-Webster Dictionary. Available at: http://www.

merriam-webster.com/dictionary/role%20model. Accessed September

2, 2013.

2. Barretti M. What do we know about the professional socialization of

our students? J Social Work Educ. 2004;40:255–283.

3. Merton RK, Reader GG, Kendall PL, eds. The Student-Physician:

Introductory Studies in the Sociology of Medical Education: A Report

of the Bureau of Applied Social Research of Columbia University.

Cambridge, Mass: Harvard University Press; 1957.

4. Holton G, Robert K. Merton (4 July 1910–23 February 2003) [obitu-

ary]. Proc Am Philos Soc. 2004;148:505–517.

5. Swick HM, Szenas P, Danoff D, Whitcomb M. Teaching professional-

ism in undergraduate medical education. JAMA. 1999;282:830–832.

6. Cruess SR, Cruess RL, Steinert Y. Role modeling—making the most of

a powerful teaching strategy. Br Med J. 2008;336:718–721.

Competency 13. Provide appropriate supervision

Carol Carraccio, MD, MA

BACKGROUND: The definition of supervision embracesboth the promotion of professional development and theassurance of patient safety, with positive effects on both pa-tient outcome and trainee development when direct super-vision is combined with focused feedback.1 Review of theliterature highlights the critical importance of the relation-ship between the supervisor and the supervisee. To buildthis relationship, there must be continuity over time, reflec-tion by both parties, and the ability of the supervisee tohave some control over and input into the supervisory pro-cess.1 Helpful supervisory behaviors include giving directguidance, aligning theory with practice, joint problemsolving, and offering feedback, reassurance, and rolemodeling.1

ROLE IN PROFESSIONAL DEVELOPMENT AND PATIENT

SAFETY: When thinking about the role of supervision inpromoting professional development, there is an importantconstruct to be considered. Ten Cate et al2 speak to the deli-cate balance between guidance and self-regulation; toomuch or too little of either may have adverse effects onlearning. “Constructive friction” is the name given to thisbalance, which is related to Vgotsky’s zone of proximaldevelopment (ZPD).2,3 The latter is described as the dis-tance between the actual developmental level, as deter-mined by independent problem solving, and the level ofpotential development when problem solving under theguidance of a more capable peer or more senior teacher.3

According to Vgotsky,3 the most essential feature is that

http://www.merriam-webster.com/dictionary/role%20model

http://www.merriam-webster.com/dictionary/role%20model













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Figure. Zones of proximal development (figure developed by Daniel J. Schumacher, MD, MEd).


the “developmental process lags behind the learning pro-cess; this sequence then results in zones of proximal devel-opment.” Harland4 builds upon this construct by speakingto the need for scaffolding, or providing higher levels ofinitial support for learners as they enter a new ZPD, andthen gradually pulling back the support as they progress to-ward independence. As one scaffold is withdrawn, a newone is built for the learner as she enters a new ZPD.

As an example of a ZPD, consider the resident coveringas night float when she encounters a child with an unfamil-iar clinical situation. Her experience allows her to applywhat she learned in caring for patients with similar signsand symptoms, ultimately diagnosed with scarlet fever, toinitiate a diagnostic workup and supportive care for thisnew patient. She calls her attending with the laboratory re-sults, and he asks her to prioritize her differential diagnosis.He leads her in formulating a differential expanded beyondscarlet fever, which ultimately includes an accurate diag-nosis of Kawasaki disease. This is an example of the gapbetween her actual developmental level and her potentialdevelopmental level with senior guidance, as illustratedby ZPD 1 in the Figure. By providing a higher level of sup-port as she entered this new ZPD, she learns new informa-tion and skills that take her to the next developmental levelof competence.When later confronted with a child who hasstreptococcal toxic shock syndrome who presents withsome similar signs and symptoms, but this time in ex-tremis, she is able to immediately intervene and stabilizethe child while calling for help. In this way, she demon-strates her ability to enter ZPD 2 (Figure), and with men-tored support, again, she learns new information andskills that will take her to the next developmental level ofcompetence. As she transcends each ZPD, she widensher realm of certainty and pushes further into her realmof uncertainty. The latter continually changes as she closesthe gap between her actual and potential developmentallevels within each successive ZPD.

Before we can assimilate this and relate it in a meaning-ful way to supervision, one more construct needs to beintroduced: capability. Fraser and Greenhalgh5 definecapability as “the extent to which individuals can adaptto change, generate new knowledge, and continue toimprove their performance.” In contrast, they definecompetence as what “individuals know or are able to doin terms of knowledge, skills and attitudes.”5 Of note,they emphasize “capability is enhanced through feedbackon performance and the challenge of unfamiliar contexts.”5

In the above example, the resident demonstrated compe-tence in caring for the familiar child with scarlet fever.When confronted with the child who had Kawasaki diseaseas well as the onewith toxic shock, she demonstrated capa-bility in caring for these patients. It is here that the strikinganalogy with supervision unfolds. In order to balance the 2goals of supervision, it is essential to determine a trainee’scurrent level of competence and then provide the degree ofsupport or scaffolding needed. In the case of supervision,the goal is the minimal type of supervision needed toensure the safety of the patient. This requires continuousreevaluation of the support or scaffolding needed and thegradual shift to a lesser degree of supervision as the traineebecomes more capable. This process is an iterative one thatallows for progressive self-regulation and fulfills the ulti-mate goal for the trainee to practice without direct supervi-sion.When thinking about the relationship between super-

vision and patient safety, the most enlightening literaturecomes from the work of Kennedy and colleagues6–8 andfocuses on the facet of supervision that they term “clin-ical oversight.” Effective clinical oversight requires thealignment between the clinical skills of the superviseeand the supervisory skills of the physician providingthe oversight. The complexity of this competency isbased on the need for the supervisor and the superviseeto move along the developmental continuum in tandem.


A supervisee requires interaction with a supervisor whois developing or has developed the skills to progressivelymove along a continuum that provides the type of super-vision that balances patient safety with the professionalformation of the supervisee. In order to attain the mile-stones that span this developmental continuum, bothsupervisees and supervisors need to continually operatewithin their respective ZPDs, with the former devel-oping the capability to expand their clinical skills in or-der to ultimately practice without direct supervision andthe latter developing their ability to step back fromdirect care, judge the competence and capabilities oftheir supervisees, and award them the appropriateamount of self-regulation to balance safe patient carewith continuous professional development.TYPES OF CLINICAL OVERSIGHT: Clinical oversight hasbeen described in terms of the following levels of supervi-sion: routine, responsive, direct care, and back stage.6 Thetype of oversight is context specific; each trainee may needdiffering types of supervision based on experience and thecurrent clinical situation.

ROUTINE OVERSIGHT

Routine oversight is supervision that is planned inadvance, such as rounds or precepting in clinic, wherethe expectation from the beginning is that every case is re-viewed.6 This type of oversight involves discussion, prob-ing, confirmation, and refinement. In essence, theseactivities can be encompassed under the broad heading ofmonitoring.

RESPONSIVE OVERSIGHT

Responsive oversight goes beyond the routine and in-volves an escalation in intensity based on the needs of thepatient, the trainee, or the supervisor. “Situation-specifictriggers for responsive over-sight involve 3 main cate-gories: 1) clinical cues, 2) information from a secondarysource, and 3) language discrepancies/inconsistencies inclinical information.”6 Examples of these categoriesinclude, respectively, 1) a presentation about an infant inwhich “lethargic” is used to describe the general appear-ance of the infant that the learner assesses as having an up-per respiratory infection; 2) the nurse’s triage note differsfrom the story that the resident is presenting; and 3) theCBC demonstrates a significant left shift in a child with afever who the trainee describes as fine and plans to sendhome from the ED without further workup or follow-up.Prior experience with a trainee can also stimulate respon-sive oversight, such as when past encounters have demon-strated trainee-specific red flags (eg, inaccuracies inphysical examination).

DIRECT CARE

When a supervisor feels the need to go beyond respon-sive oversight, he becomes involved in direct patientcare. The latter may be limited to a specific aspect ofcare or to taking over care based on concerns regarding atrainee’s competence.6 An example is precepting in clinic

when the trainee’s recounting of the history and physicalexamination does not make sense, and upon going backinto the room, the supervisor encounters a very sick patientand immediately takes over care based on the trainee’s lackof recognition of illness severity.

BACKSTAGE SUPERVISION

Backstage supervision, unlike the types of clinical over-sight described previously, involves checking that is nottransparent to the learner.6 An example is the supervisorwho reviews the laboratory values on a patient before com-ing to rounds, although he knows that these values will bepresented during the case discussion.In addition to these types of supervision described by

Kennedy and colleagues,6 we propose another type of su-pervision: retrospective supervision. This type of supervi-sion is exercised as a stopgap measure to ensure thatelements of prospective supervision did not fail. Retro-spective supervision is most appropriate for learners forwhom supervision from a distance is warranted. Anexample of this type of supervision is when a faculty mem-ber reviews charts from the prior day’s clinic visits, ensuresthat documented care is appropriate, and gives either writ-ten or verbal feedback to the resident, allowing patientsafety and learner professional development to be opti-mized.For the supervisor, patient safety, direct observation of

a trainee’s skills, experience with and knowledge of thetrainee’s limits, perceived level of complexity of thetask, feedback from others who have worked with thetrainee, and the local clinical environment have all beendescribed as playing a role in his ability to grantincreasing independence.9 Trainee confidence and self-ef-ficacy, as well as supervisor “audacity,” were also a partof the supervisor’s decision to provide less intense clin-ical oversight.9 The qualitative study by Kennedy et al7

of how supervisors determine the intensity of the over-sight provided found that 4 dimensions are influential:knowledge and skill, discernment (ability to identifylimits), conscientiousness, and truthfulness. These 4 di-mensions formed the basis for what they termed “trust-worthiness.” (See the competency on trustworthiness fora detailed explanation).10

DEVELOPMENTAL MILESTONES:MILESTONES FOR SUPERVISOR

� Supervisor’s limited experience in this role makes it difficult to stepback from direct care.

� Supervisor recognizes the need to entrust care to his supervisee, butis not able to accurately assess the current level of competence of thetrainee. This results in a mismatch between the level of competenceof the trainee and the type of supervision provided, particularly fortrainees who are not at either end of the performance spectrum.

� Supervisor accurately assesses the competence of the trainee and isable toalign typeof supervision todemonstrated level of competence.However, apersonal need for greater involvement incareoften resultsin an inability to empower the trainee to reachbeyondher current levelof comfort and competence to become capable of dealing with lessfamiliar types of patients and clinical circumstances.


� Supervisor accurately assesses both the competence and thecapability of the trainee and provides a level of supervision thatbalances patient safety with the trainee’s professionaldevelopment. Is dependent on a self-directed supervisee to providethe needed resources to support her own learning in managing lessfamiliar types of patients and clinical circumstances (eg, the traineewho seeks out new learning opportunities, such as asking to do aprocedure that she has never done before when her supervisordoes not offer this experience).

� Supervisor accurately assesses the competence as well as thecapability of the trainee, aligning the type of supervision to maximizeand balance patient safety and the trainee’s professional growth.Continuously evaluates the potential for the trainee to develop newcapabilities and adjusts the type of supervision necessary tooptimize professional development.

MILESTONES FOR SUPERVISEE

� Supervisee requires direct supervision to ensure safety and qualitycare for the patient based on inability to demonstrate many or all ofthe following: required content knowledge, skills, knowledge oflimitations, conscientiousness, and/or transparency/truthfulnessabout limitations

� Supervisee requires direct supervision in most cases. In previouslyencountered situations, responsive supervision is warranted basedon transparency/truthfulness, conscientiousness, fundamentalcontent knowledge, and skills but uncertainty about limitations (notenough experience to know what she doesn’t know).

� Supervisee demonstrates competence, requiring routinesupervision in most cases based on transparency/truthfulness,conscientiousness, content knowledge and skill, andacknowledgment of limitations. May require responsive supervisionor, rarely, direct care in cases of high acuity and/or complexity.

� Supervisee’s ability to demonstrate competence, combined withtrustworthiness (knowledge/skill, knows limits, conscientiousness,truthfulness), allows for supervision at a distance, with thesupervisee calling the supervisor as needed. The trainee often relieson her supervisor for prompts to expand her learning when enteringunfamiliar clinical situations, but she demonstrates capability whengiven appropriate support to do so.

� Supervisee is ready to practice without direct supervision based notonly on competence but also on demonstrated capability in safelycaring for patients with unfamiliar problems and the drive tocontinually push herself beyond her realm of experience into newclinical circumstances; self-regulates and judges level of supportneeded for safe and quality patient care as she expands hercapabilities.

REFERENCES

1. Kilminster SM, Jolly BC. Effective supervision in clinical practice

settings: a literature review. Med Educ. 2000;34:827–840.

2. Ten Cate O, Snell L, Mann K, Vermunt J. Orienting learning toward

the teaching process. Acad Med. 2004;79:219–228.

3. Vgotsky L. Interaction between learning and development. In:

Mind and Society. Cambridge, Mass. Harvard University Press;

1978:79–91.

4. Harland T. Vgotsky’s zone of proximal development and

problem-based learning: linking a theoretical concept with

practice through action research. Teach Higher Educ. 2003;

8:263–272.

5. Fraser SW, Greenhalgh T. Coping with complexity: educating for

capability. Br Med J. 2001;323:799–803.

6. Kennedy TJT, Lingard L, Baker GR, et al. Clinical oversight: concep-

tualizing the relationship between supervision and safety. J Gen

Intern Med. 2007;22:1080–1085.

7. Kennedy TJT, Regehr G, Baker GR, Lingard L. Point-of-care assess-

ment of medical trainee competence for independent clinical work.

Acad Med. 2008;83:S89–S92.

8. Kennedy TJT. Towards a tighter link between supervision and trainee

ability. Med Educ. 2009;43:1126–1128.

9. Dijksterhuis MGK, Voorhuis M, Teunissen PW, et al. Assessment of

competence and progressive independence in postgraduate clinical

training. Med Educ. 2009;43:1156–1165.

10. Hicks PJ, Schumacher DJ, Guralnick S, Carraccio C, Burke AE.

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Domain of Competence: Patient Care · 2015. 11. 6. · Competency 2. Organize and prioritize responsibilities to provide patient care that is safe, effective, and efﬁcient Daniel