Overcoming the Barriers to Implementing the Evaluation of the Competencies
Journal of Academic Ophthalmology 2010, Volume 3, Number 1 1 The implementation process for the Accreditation Council for Graduate Medical Education (ACGME) competencies' mandate continues to plague program directors in ophthalmology. In this editorial I will ar-gue for specific steps to overcoming the local institu-tional and national organizational barriers to success-ful implementation of the mandate. These eight steps include: 1) Ending denial and embracing the ACGME mandate fully, 2) Defining a strategic vision plan by creating a competency based curriculum, 3) Identify-ing and removing the structural barriers (i.e., time, money, people) to success, 4) Publicizing the mission and creating a sense of urgency among the partici-pants, 5) Establishing an in house Task Force for the competencies to serve as a home for a like-minded cadre of intramural champions and a guiding coalition of the willing, 6) Creating short term wins by using proven standardized methods of assessment first and then customizing them to local institutional and na-tional subspecialty needs, 7) Embedding the change within the local institutional and departmental culture to insure sustainability, and 8) Going slow but steady, picking the low hanging fruit, and taking small bites. The first and most critical step is ending denial about the purpose of the ACGME Outcome Project. The creation of a competency based curriculum should be undertaken not because it is an ACGME requirement and not because it is some passing educational fad but because we all care about patients and our residents and more importantly we want to improve patient care safety, satisfaction, quality, and cost effectiveness through an improved graduate medical education framework. The outcome of the Outcome Project should be improved patient care downstream and we should act on the implementation with the end in mind. My 7-year-old daughter, Rachael is an avid learner in Tae Kwon Do. Tae Kwon Do is based upon a clear and explicit competency based curriculum. One day my daughter asked me Dad, how many years? To which I replied: What? She asked me again more emphatically: How many years do I have to go to class to get my black belt in Tae Kwon Do? I re-sponded (tongue in cheek) that it doesn't work like that, you have to progress through defined Dreyfus stages, engage in Ericsson's deliberate practice, and you must self reflect on your progress with the Schon model. To which my daughter responded in a very puzzled voice: Huh....Daddy...just tell me how many years? The sad reality and the point of this story is that unlike Tae Kwon Do it takes precisely one year to become a post-graduate year (PGY) 1 intern and exactly 3 more PGYs to become a practicing ophthal-mologist... regardless of what belt you actually hold. In other words the apprenticeship model is time based (PGY) and not competency based. Fundamentally to me this limitation is the best reason to move towards a competency based model of education. In order to succeed, our three core resources (e.g., time, people, money) need to be allocated better to create a sustainable effort especially in these challeng-ing economic times. One key recommendation that I would make is to use resources more efficiently by asking the right person, the right question, and at the right time. This means that some faculty in your de-partment won't, can't (and shouldn't) participate in the process. For example we should not ask a faculty member who exhibits less than professional behaviors to rate the resident on professionalism. The chairman should find some other ways for these non-like minded persons to contribute to Department outside of education. I would suggest in fact that you Ask Overcoming the Barriers to Implementing the Evaluation of the Competencies Andrew G. Lee, MD 1,2*