Insight Matters
Fall, 2001

President's Column:
Competency-Based Training is the Future of Psychiatric Education

Are you a competent physician? a competent psychiatrist?

Do you maintain and continuously improve your clinical abilities?

Have you achieved the appropriate knowledge, skills and attitudes for the practice of psychiatry in the 21st century?

These are questions psychiatric educators are facing today. True, none of us in residency training exactly set out to graduate incompetent physicians before now; none of us went through our own residencies expecting not to learn how to practice our chosen profession... but as of this year, residency training programs are required to certify that graduates of our program have had more than the opportunity to learn; but that they are indeed competent to practice our profession now, and into the future.

The formal shift from traditional to competency-based training began in 1999, with the ACGME's declaration of six "general competencies" expected of all graduates of ACGME-approved training programs, in the areas of Patient Care; Medical Knowledge; Practice-based Learning; Interpersonal and Communication Skills; Professionalism; and Systems-based Practice. The ACGME "Outcomes Project" further delineated objectives for each competency: For example, objectives for Patient Care competencies include that the competent physician will...
- communicate effectively and demonstrate caring and respectful behaviors;
- gather and record essential and accurate information;
- make informed diagnostic and therapeutic decisions;
- counsel and educate patients and their families regarding their illnesses;
- competently (there's that word again!) perform essential procedures;
- practice preventive medicine (including both primary and secondary prevention); and
- work effectively with other healthcare disciplines.

The Outcomes Project goes on to urge programs to develop the means to determine trainees' knowledge, skills and attitudes related to these objectives. Starting from the examples above, we might consider the following:
- knowledge of appropriate diagnostic procedures and effective therapeutic interventions;
- knowledge of prevention techniques and health maintenance strategies;
- skills in effective communications and accurate information gathering;
- skills in performing "essential procedures" and in patient/family education;
- attitudes of care and respect for patients and their families;
- attitudes of respect and valuing multidisciplinary approaches to patient care;
and from these determine appropriate methodologies to "measure" competence.

All of which begs the central question: What is competence?

According to Webster, the term comes from the Latin competencia, meaning "a meeting or agreement;" and is defined as "1. Sufficient means for one's needs; 2. Condition of being competent: Ability, fitness; 3. Legal capacity."

To borrow from our forensic colleagues, when asked if one is "competent," our first response should be: "To do what?" Competence is not then considered a permanent and unalterable "state." Rather it is considered a relative condition, dependent upon the capacity of the individual at a given time to perform a particular task or number of tasks, taking into account any number of conditional variables.

So then, what should be the competencies by which psychiatrists should be measured?

In 2001, the Psychiatry RRC of the ACGME in consultation with the American Board of Psychiatry and Neurology, the American College of Psychiatry and the American Psychiatric Association included five "Psychiatry-specific" competencies in the new Essentials of Accredited Programs. The areas for which each psychiatry training program must now demonstrate its graduates "competency," and by which each program's continuing accreditation will be partially assessed, include five psychotherapeutic modalities:

- brief therapy;
- cognitive-behavioral therapy;
- psychodynamic psycotherapy;
- supportive therapy; and
- combined psychotherapy and psychopharmacology.

Programs are challenged to determine appropriate knowledge, skill and attitudinal objectives and to measure trainees' acquisition of competence in these areas, as well as to develop further program-based competencies, in such potential areas as pharmacology, ECT and other somatic therapies; addiction, child and adolescent, forensic, and geriatric psychiatry; consultation, quality improvement, rehabilitative technologies, community-based systems of care delivery...and whatever else we may deem important and essential to the future of our profession.

So again, how will we determine competence in any one of these areas? Is competence the acquisition and demonstration of knowledge, skills and attitudes? Is it the coalescence of all three into something beyond? Is it performance? And at what place on the continuum, from novice to expert, should we consider our trainees, or ourselves, as competent?

We may need to look to the question of how we teach, rather than what we teach: We dispense knowledge through didactic instruction, reading and discussion, and supervision. Skills are taught through demonstration and observation (the proverbial "see one, do one, teach one" of traditional medical education). We may attempt to impart attitudes through explicit (instructional) or implicit (modeling) behaviors...but somehow attitudes seem a different realm than knowledge and skills; an amalgamation of predisposition and receptiveness that perhaps cannot be exactly "taught..." Much as perhaps competence cannot be taught but must somehow be acquired.

How we assess what is learned may also need to be reconsidered: Our traditional assessment tools include oral and written examination of knowledge (i.e. PRITEs, oral exams); observation and documentation of skills (supervision, case-logs); and subjective impressions of attitudes by supervisors and mentors. The Outcomes Project provides a "Toolbox of Assessment Methods," introducing the uninitiated to such measures as 360-Degree Evaluation, Chart Stimulated Recall Examination (CSR); Objective Structured Clinical Examination (OSCE); patient/family survey instruments and others.

We may need to reconsider distinctions between formative (instructive) and summative (outcomes) evaluation, and their relative roles in determining competence. Other assessment issues to consider include the instruments' generalizability, reliability, validity and feasibility; i.e. do the outcomes accurately predict future performance? in non-identical situations? and do we have sufficient resources to use them?

The good news, for programs like ours who will be Site-Reviewed in the coming weeks, is that in 2001 we are not expected to have worked out all the answers to these issues. We do need to demonstrate that we are engaged in this process however; and it is clearly a process that must involve us all, whether trainee or graduate; educator, clinician or researcher; faculty member or community-based clinician.

These are the standards by which we will choose to measure ourselves now and in the future, and which will inevitably impact the directions we take as a profession. I urge you to become involved: Through our professional organizations, through your local training committees, through your contributions as a supervisor or mentor to a medical student, an MIT or early-career psychiatrist.

And while we're at it, shouldn't we go beyond "competence..." to begin considering what might constitute "excellence?"

Robert J. Ronis, M.D., M.P.H.
President of OPA

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