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Core competency work in the US is much newer than in Canada. The ripples of change accompanying its introduction are currently being felt strongly in residency training programs, and the American Board of Medical Specialties’ newly mandated Maintenance of Certification Program will soon affect all medical specialties. This article provides an update on the educational and certification implications of psychiatric core competencies in the US. The differences in making medical care core competencies operational in Canada and the US are significant. For the most part, all aspects of medical education and certification are institutionally more complicated in the US than in Canada. The following list indicates some of the ways in which work with medical core competencies differs between the 2 countries: 1. According to the CanMEDs 2000 Project Report, Canadian medical specialists’ roles determine the tasks they must accomplish (1). These roles include the following: medical expert (or clinical decision maker), communicator, collaborator, manager, health advocate, scholar, and professional. In contrast, core competencies for American medical specialists are grouped into 6 broad categories: patient care, medical knowledge, interpersonal and communications skills, practice-based learning and improvement, professionalism, and systems- based practice. 2. The Royal College of Physicians and Surgeons of Canada (RCPSC) has handled implementation of the role framework for competencies in Canada. Because the RCPSC handles both medical specialty training and certification, the role framework has been introduced into all aspects of postgraduate medical specialty education. By contrast, in the US, separate groups handle graduate medical education and specialty certification. The Accreditation Council for Graduate Medical Education (ACGME) accredits graduate residency programs in the various medical specialties, and the American Board of Medical Specialties (ABMS) is the umbrella organization of the 24 medical specialty boards, which handle individual physician certification. Thus, with separate agencies in charge of different segments of a physician’s educational and professional career, it can be said that there is no single American equivalent of the RCPSC. 3. Sheer numbers in the US also complicate the implementation of medical specialty core competencies. For example, where Canada has 16 medical schools with 16 psychiatry residencies, the US has 125 medical schools and 179 psychiatry residencies. In addition, while in Canada the RCPSC governs the 58 medical specialties and provides uniform administration of the competencies, in the US the ABMS has 24 separate member medical certification boards. Each certification board is responsible for one or more specialties and, in many cases, for several subspecialties. For example, the ABPN certifies 2 specialties and 7 subspecialties (some of the subspecialties in conjunction with other certification boards). This diffusion of authority does not permit uniform administration of core competencies. The size, scope, and varying governing bodies of institutions in the US present a challenge to the uniform implementation of a core competency program. A Brief History of Competence in Relation to Psychiatric Practice in the USMedical core competencies in the US grew out of a focus on educational outcomes. University of Chicago professor Ralph Tyler stressed that educational outcomes should be guided by objectives written in behavioural terms. The success of educational activities should be judged by how well students achieve measurable outcomes (2). The concept of core competencies became increasingly important in the 1980s, when the US Department of Education mandated outcome measures for all educational projects, including those involving accreditation. “Heavily funded medical education systems, having greatly expanded during the 1970s, were a prime target of this initiative and were called upon to provide evidence of responsible stewardship in preparing competent physicians to meet public health care needs. Various groups, meeting through the 1990s, developed objectives to assess or measure these educational outcomes within medicine. Some groups concentrated on attributes of competence while others focused more on performance issues. These outcomes eventually came to be referred to as necessary, or ‘core,’ competencies” (3). The work products of these various groups were remarkably similar. Two such groups were the ACGME and the ABMS. In September 1999, after much work individually, they agreed on 6 categories of core competencies, thus providing a framework within which to progress with medical core competencies in the US. The 6 agreed-upon core competency categories are as follows:
About the time that the ACGME announced it would be mandating the implementation of medical core competencies in residency programs, the ABMS announced that its specialty boards should work to determine the relevance of the core competencies to specialties and subspecialties. Relevant core competencies in each of the 6 categories were then to be assessed as part of the initial certification procedure and at least once during a board’s repeating maintenance of certification cycle. To assist in defining the core competencies, working groups known as “quadrads” were formed for each specialty. The quadrads were to list specific competencies for their specialties in each of the above-noted core competency areas. Each quadrad comprised 1 member representing an ABMS certification board, 1 member representing the ACGME, 1 residency program director, and 1 resident physician in the specialty. The ABPN Process for Defining Psychiatric Core CompetenciesIn June 2001, to validate and extend the quadrads’ work, the ABPN invited American and Canadian leaders of both specialties to a conference in Toronto. Conference participants reviewed and revised the merged core competency outline of the psychiatry and neurology quadrads. In addition, they assigned a priority rating to each competency, determined when during the residency–certification–maintenance of certification cycle the competency should be assessed (in some cases, more than once), and suggested possible assessment methods. The amended core competency outline was then given to the ABPN Core Competencies Committee, which was charged with the following tasks: 1. To develop an infrastructure for ongoing survey, review, and validation of core psychiatric and neurological competencies 2. To determine which core competencies should be assessed during the traditional ABPN initial certification processes and which through the ABPN Maintenance of Certification Program The ABPN Executive Committee assured the Core Competency Committee of Board support in the integration of the core competencies by having discussions with appropriate agencies and organizations The Psychiatric Core Competencies EnumeratedAppendix 1 lists psychiatry core competencies. While the core competencies listed in the categories of interpersonal and communications skills, practice-based learning and improvement, professionalism, and systems-based practice were essentially the same for both psychiatry and neurology, serious dichotomies were found in the categories of patient care and medical knowledge. Because the ABPN represents 2 specialties, the Board took care to list competencies that relate to each. Leadership of the ABPN agreed that some patient care and medical knowledge core competencies were common for both psychiatry and neurology but that each specialty also had to list its own specialty-specific core competencies. Therefore, the patient care and medical knowledge categories each contain a general, a psychiatry-specific, and a neurology- specific section. (Appendix 1 lists only the general and psychiatric sections of these categories.) The ABPN Board approved this outline of psychiatry core competencies on January 9, 2003. Implications of the Psychiatric Core Compet- encies for Psychiatric Education in the USThe ACGME has required that, as of July 1, 2002, each accredited medical residency program in the US develop a plan to assess its residents according to specialty-specific core competencies. This mandate has created the need for increasing dialogue between residency programs and the ABPN. The ultimate outcome of this partnership should be systematic procedures for listing those competencies for which residents will be held accountable and upon which physicians will be assessed for initial and continuing certification. Implications of Psychiatric Core Competencies for Psychiatric Practice in the USFollowing the ABMS directive, the ABPN changed its practice of issuing lifetime certificates to issuing 10-year certificates after October 1994. For ABPN diplomates earning the new certification, this initially meant that they would be required to recertify every 10 years by offering proof of their licensure and by taking a cognitive examination. This process has now expanded into a maintenance of certification process that requires more focused activity on the part of the diplomates. Now, in addition to providing evidence of current licensure and cognitive expertise, diplomates will also be asked to provide evidence of having participated in a self- assessment process and in a lifelong learning program. In the future, an assessment of performance in practice will also be added to the maintenance of certification requirements. The ABMS has mandated maintenance of certification programs for all the US medical certification boards. The boards have also been charged with determining the relevance of the core competencies to their individual specialties and with ensuring that the relevant core competencies are assessed at least once during each board’s maintenance of certification cycle. Psychiatric Core Competencies in the Future in the USAttempting to predict the importance and the implications of core competencies in the future would require foresight, but certain trends in health care make likely premises clear. Primary among these is the current trend toward greater measurable accountability on the part of all professionals. Physicians, once seen as almost omnipotent, are now asked for their credentials and their performance track records. Two main factors support this major trend. The first is increased competition in the US among health care providers for fewer insurance dollars, with money being allocated to those who can objectively verify their competence. This applies both to physicians in private practice and to those who practise in the public sector. Board certification can be seen as more important than ever. The second factor supporting this trend is the medical profession’s effort to take responsibility for monitoring its own members. This self-monitoring has the ultimate benefit of the patients in mind, but a practical consideration is that if the medical profession does not monitor itself, an external agency may be established to do so. In any case, defined specialty core competencies potentially facilitate greater measurable accountability of individual physicians. This can be seen as a benefit both to patients and to the profession itself. Further, core competencies as they relate to the recertification of physicians provide a handy litmus test for insurance carriers. ConclusionHolding physicians accountable for their competence is not a new idea, but having uniform standards by which to assess such competence is new. Measurement systems in Canada and the US are essentially very similar, but the Canadian organization of medical education and certification under a single agency, the RCPSC, is more efficient than the US system. References1. The Royal College of Physicians and Surgeons of Canada. CanMEDS 2000 Project Report. Ottawa (ON): The Royal College of Physicians and Surgeons of Canada; 1996. 2. Tyler RW. Basic principles of curriculum and instruction: syllabus for education 360. Chicago (IL): University of Chicago Press; 1949. 3. Scheiber SC, Kramer TAM, Adamowski SE, editors. Core competencies for psychiatric practitioners: what clinicians need to know. Philadelphia (PA): APPI; 2003. Appendix 1PSYCHIATRY CORE COMPETENCIESPatient CareGeneral 1. The physician shall demonstrate the ability to perform and document a relevant history and examination on culturally diverse patients (Note 1) to include as appropriate
2. The physician shall demonstrate the ability to delineate appropriate differential diagnoses. 3. The physician shall demonstrate the ability to evaluate, assess, and recommend effective management of patients. For Psychiatry 1. Based on a relevant psychiatric assessment, the physician shall demonstrate the ability to develop and document the following:
2. Based on a comprehensive psychiatric assessment, the physician shall demonstrate the ability to comprehensively assess and document potential of the patient for self-harm or harm to others. This shall include the following:
3. Based on a comprehensive psychiatric assessment, the physician shall demonstrate the ability to do the following:
4. Based on a comprehensive psychiatric assessment, the physician shall demonstrate the ability to recognize and treat psychiatric disorders. Medical KnowledgeGeneral 1. The physician shall demonstrate knowledge of the major disorders, including considerations relating to age, sex, race, and ethnicity, based on the literature and standards of practice. This knowledge shall include the following:
2. The physician shall demonstrate knowledge of health care delivery systems, including patient and family counselling. 3. The physician shall demonstrate knowledge of the application of appropriate ethical principles in delivering medical care. 4. The physician shall demonstrate the ability to reference and use electronic systems to access medical, scientific, and patient information. For Psychiatry 1. The physician shall demonstrate knowledge of human growth and development, including normal biological, cognitive, and psychosexual development, including sociocultural factors. 2. The physician shall demonstrate knowledge of behavioural science and social psychiatry, including the following:
3. The physician shall demonstrate knowledge of patient evaluation and treatment selection, including diagnostic and therapeutic studies, including the following:
4. The physician shall demonstrate knowledge of psychiatric subspecialties and other areas of psychiatric endeavour, including the following:
5. The physician shall demonstrate a knowledge of neurology, including the following:
Interpersonal and Communications Skills1. The physician shall demonstrate the abilities to do the following:
2. The physician shall demonstrate the ability to obtain, interpret, and evaluate consultations from other medical specialties. This shall include the following:
3. The physician shall serve as an effective consultant to other medical specialists, mental health professionals, and community agencies. The physician shall demonstrate the ability to do the following:
4. The physician shall demonstrate the ability to communicate effectively with patients and their families by
5. The physician shall maintain up-to-date medical records and write legible prescriptions. These records must capture essential information while simultaneously respecting patient privacy, and they must be useful to health professionals outside psychiatry and neurology. 6. The physician shall demonstrate the ability to effectively lead a multidisciplinary treatment team, including being able to
7. The physician shall demonstrate the ability to communicate effectively with patients and their families while respecting confidentiality. Such communication may include
Practice-Based Learning and Improvement1. The physician shall recognize limitations in his or her own knowledge base and clinical skills, and understand and address the need for lifelong learning. 2. The physician shall demonstrate appropriate skills for obtaining and evaluating up-to-date information from scientific and practice literature and other sources to assist in the quality care of patients. This shall include, but not be limited to, the following:
3. The physician shall evaluate caseload and practice experience in a systematic manner. This may include the following:
4. The physician shall demonstrate an ability to critically evaluate relevant medical literature. This ability may include the following:
5. The physician shall demonstrate the ability to do the following:
Professionalism1. The physicians shall demonstrate responsibility for his or her patients’ care, including the following:
2. The physician shall demonstrate ethical behaviour, integrity, honesty, compassion, and confidentiality in the delivery of care, including matters of informed consent or assent, professional conduct, and conflict of interest. 3. The physician shall demonstrate respect for patients and their families and for colleagues as persons, including respect for their ages, cultures, disabilities, ethnicities, sexes, socioeconomic backgrounds, religious beliefs, political leanings, and sexual orientations. 4. The physician shall demonstrate understanding of and sensitivity to end-of-life care and issues regarding provision of care 5. The physicians shall review his or her professional conduct and remediate when appropriate. 6. The physician shall participate in the review of the professional conduct of colleagues. 7. The physician shall be aware of safety issues, including acknowledging and remediating medical errors, should they occur. Systems-Based Practice1. The physician shall have a working knowledge of the diverse systems involved in treating patients of all ages and understand how to use the systems as part of a comprehensive system of care in general and as part of a comprehensive, individualized treatment plan. The physician shall be able to do the following:
2. In the community system, the physician shall be able to do the following:
3. The physician shall demonstrate knowledge of and interact with managed health systems, including the following:
4. The physician shall demonstrate knowledge of community systems of care and assist patients to access appropriate care and other support services. This requires knowledge of treatment settings in the community, which include ambulatory, consulting, acute care, partial hospital, skilled care, rehabilitation and substance abuse facilities; halfway houses; nursing homes and home care; and hospice organizations. The physician should demonstrate knowledge of the organization of care in each relevant delivery setting and the ability to integrate the care of patients across such settings. Notes1. Cultural diversity includes issues of race, sex, language, age, country of origin, sexual orientation, religious and spiritual beliefs, sociocultural class, educational and intellectual levels, and physical disability. Working with a culturally diverse population requires knowledge about cultural factors in the delivery of health care. For the purposes of this document, all patient and peer populations are to be considered culturally diverse. 2. Regarding sociocultural issues, for the purposes of this document, “family” is defined as those having a biological or otherwise meaningful relationship with the patient. Such “significant others” are to be defined from the patient’s point of view. Author(s)Manuscript received and accepted March 2003. 1. Executive Vice President, American Board of Psychiatry and Neurology, Inc, Deerfield, Illinois. 2. Director, Student Counseling and Resource Center, University of Chicago, Chicago, Illinois. 3. Director, New Assessment Initiatives, American Board of Psychiatry and Neurology, Inc, Deerfield, Illinois. Address for correspondence: American Board of Psychiatry and Neurology, Inc, 500 Lake Cook Road, Deerfield, IL 60015
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