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Perspectives |
Part I. The Health Professions1 James H. Thrall, MD
1 From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Founders House 216, 55 Fruit St, Boston, MA 02114. Received February 15, 2006; final version accepted February 20. Address correspondence to the author (e-mail: jthrall{at}partners.org).
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INTRODUCTION |
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 TOP INTRODUCTION References |
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NEW CORE COMPETENCIES: IOM REPORT
One of the important recommendations of the IOM report Crossing the Quality Chasm: A New Health System for the 21st Century (2) was the convening of an interdisciplinary summit to map out steps aimed at reforming the education of health professions to achieve better quality and safety. This summit was held in June 2002, and the IOM has presented the resulting findings and recommendations in a publication titled Health Professions Education: A Bridge to Quality (4). Attendees at the summit included physicians, nurses, pharmacists, individuals associated with other health professions, representatives of associations and organizations related to health professions, and representatives of various governmental organizations and educational institutions.
Although the IOM report on new educational directions is aimed primarily at medical, pharmacy, and nursing education, the work of the summit is somewhat groundbreaking because it explicitly recognizes the importance of the so-called "allied health professions," which the report assembles into 10 categories on the basis of an earlier report by the IOM (5). The Health Professions Career and Education Directory (6), which is published annually by the American Medical Association, currently lists 65 separate curricular pathways associated with the allied health professions. This impressive number supports the observation in the IOM report (5) that "the committee acknowledges that defining what is meant by the term allied health and specifying the disciplines it encompasses is problematic."
The IOM's inclusion of the allied health professions is welcome because previous failure to recognize the importance of allied health providers in the care delivery process has helped perpetuate an elitist outlook within the professional hierarchy of health care. More importantly, the underestimation of the potential of different groups to contribute and the full integration of these groups into the care process has impeded efforts to improve quality and safety and has kept costs higher than necessary by arbitrarily restricting the services delivered by allied health workers.
The IOM summit committee identified five core competencies (7) needed for all health professionals, as summarized in the following statement: "All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches and informatics." Each of these core competencies has subcomponents and, in sum, they support the six principles enunciated in Crossing the Quality Chasm: A New Health System for the 21st Century (8), which hold that care should be safe, patient centered, effective, efficacious, equitable, and timely.
The first core competency—providing patient-centered care—sets the stage for the others. Physicians and other caregivers through the ages have undoubtedly used this intuitively as a guiding principle, without defining explicitly what it means. If there is a major change in outlook of the IOM report that reflects a contemporary versus historical view, it is in the level of communication expected between providers and patients, the level of involvement by patients in the decision-making process, and the concept of a continuous lifetime engagement of providers with patients about wellness and disease prevention rather than engagement just at times of illness. One might argue that the fundamental mission of caregivers and even hospitals has changed from the delivery of ad hoc care on behalf of acutely ill patients to the establishment of lifelong health- and wellness-based relationships that, by their very nature, must be patient centered.
The second core competency—working in interdisciplinary teams—speaks to the complexity of contemporary health care delivery. No provider is an island anymore. The days of solo medical practitioners or surgeons who do not seek or need help from colleagues are past. Any major illness or condition requires an interdisciplinary team. The health system has been slow to recognize this; patients have had to create their own interdisciplinary teams and integrate their own care by finding individual providers representing the components of care they require. The geographic distribution of practitioners in medical centers is still mainly organized by medical specialty rather than by disease or condition; this forces patients to navigate between different locations as they receive multidisciplinary care.
Cancer centers were among the first major undertakings in many institutions that manifested a truly interdisciplinary paradigm for health care delivery. Instead of forcing patients to see physicians from multiple specialties and associated nurses, nutritionists, psychologists, and other providers in multiple different locations across a medical campus without the benefit of a unified medical record, the leading contemporary cancer centers offered patients highly unified care that was provided by co-located interdisciplinary teams that had electronic access to all patient records.
The center concept fosters both patient-centered and interdisciplinary care and is being adopted for other major categories of disease in addition to cancer. As medical students and residents receive their education in the age of the electronic medical record and in the context of these interdisciplinary centers, the concept of interdisciplinary care will become firmly embedded in the culture of medical practice to the extent that it will seem odd and unusual at some point not to practice that way.
The third core competency—employing evidence-based practice—at first seems obvious and intuitive; is this not what health professionals always do as a basic consequence of their scientifically grounded training? While this may be what providers think they are doing, the degree of variation in clinical practice that is empirically observed across the health care landscape in the United States indicates that realization of the goal of evidence-based practice remains elusive (8,9).
The cornerstone of evidence-based practice is the incorporation of the best available research into clinical practice. Research may come from a variety of sources, including clinical trials, laboratory experiments, outcomes studies, technology assessments, or epidemiologic studies. For many diseases and conditions (perhaps most), these sources do not provide all of the necessary elements needed for patient care. Thus, clinical expertise in the form of knowledge gleaned through experience is also recognized as an important component of evidence-based practice (10). For example, the guidelines developed for asthma care (11) that are promulgated by the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute are based on a consensus derived by a panel of experts.
The relentless flood of new information about medical science and clinical practice is overwhelming and challenges even the most diligent physicians, nurses, and other providers to stay abreast and incorporate new knowledge into their practices. An important advantage of working in interdisciplinary teams is the efficiency gained in parsing out the responsibility for updating protocols for care to respective team members with associated expertise.
The concept of evidence-based practice also calls for incorporation of patient values and, beyond that, of patient capabilities into the care process. This aspect of care is easily overlooked and is difficult to manage without high levels of communication between the provider and the patient and an acceptance by the provider of the patient's right to be involved in the decision-making process. Providers must correctly assess the patient's desires, especially in end-of-life care. Physicians and patients may have different outlooks on sustaining life.
Physicians must also correctly assess the variable ability of their patients to understand and perform their own responsibilities in the care plan. Some patients simply cannot follow complicated instructions for administering drugs to themselves or manage glucose levels. Others may become impaired during illness and, after years of successful compliance, may no longer be able to function at a previously demonstrated level. Attempting to apply the best research evidence to achieve optimum care will fail miserably without correctly taking patient values and abilities into consideration.
The fourth core competency—applying quality improvement—is aimed at promoting improvement in all elements of the care process and promoting the objective measurement of care outcomes. The IOM report (6) specifically stresses the identification and mitigation of sources of errors and hazards, the simplification and standardization of care processes, and the application of design principles for safety.
While no one can argue against improving quality, there are innumerable impediments in consistently pursuing this goal. Objective self assessment and the acknowledgment that patients may not have received the best care possible are formidable hurdles because most providers genuinely try to provide patients with the best care and the assumed need for quality improvement may be viewed as an implied criticism of their performance. Many physicians and other health professionals are threatened by this implied criticism and are not eager participants in quality improvement initiatives that measure their performance. The IOM and other leaders have attempted to address this conundrum by stressing the importance of care systems rather than individual performance, but this issue will not go away, especially with the constant threat of malpractice exposure casting a dark shadow across the health care landscape (9).
The fifth core competency—using informatics—comes back to many of the principles emphasized in Crossing the Quality Chasm: A New Health System for the 21st Century (2). The key point is the power of working with information and knowledge management systems to reduce errors, improve communications, provide current information for decision support, and cope with the explosion of the knowledge base that underpins the practice of medicine.
The rapid adoption of electronic information systems in hospitals, including picture archiving and communications systems in radiology departments, is supporting the incorporation of informatics into practice. Students of all backgrounds now encounter information systems in the normal routine of their respective disciplines and will increasingly view informatics as intrinsic to what they do. Students will learn to use informatics systems in parallel with the rest of their training. Having entered practice without these systems, established professionals are probably a greater challenge because they may look on such systems as disruptive to successful career-long practice patterns rather than as powerful tools to achieve better quality and safety and higher efficiency.
Radiology has been a pioneer among medical disciplines in the use of computers and informatics, and members of this specialty have led the way educationally in many institutions, not only for their own trainees but also for others. Starting 15 years ago, Robert A. Novelline, MD, who serves as the Director of Medical Student Education in the Department of Radiology at Massachusetts General Hospital, began including instruction on the use of computers in the junior clerkship curriculum for Harvard Medical School students. Students learned how to access hospital and radiology information systems, electronic medical records, picture archiving and communications systems, three-dimensional processing programs, the pathology database, and the Internet to gather material for case-based computer slide presentations. Previously, very few students rotating through the department had any experience in using these systems or in making computer slides. Today, it is unusual to encounter someone without at least rudimentary skills.
The educational challenges posed by the IOM's core competencies are formidable, but (as noted) elements of each fold into supervening educational and practice trends. Progress toward achieving the core competencies is likely to gain traction as a natural consequence of these dynamics and not because anyone in great authority decides to follow the directions for educational reform posited by the IOM. This leaves unanswered the questions of whether, when, and how to best incorporate the IOM core competencies into the educational process. Health care organizations can certainly promote the core competencies by embedding them in their own processes so that, through exposure and practical experience, students from all health professions are given the opportunity to learn about them.
For physicians, there is a clear opportunity during residency training to introduce and emphasize the core competencies as trainees begin to develop a better overview on how the entire care process works. For nurses, technologists, and most others, this opportunity does not exist in the same way. Nonetheless, these core competencies should be regarded as career-long goals, and training aimed at these competencies should be included in educational curricula whenever possible, including programs for continuing education.
NEW GENERAL COMPETENCIES: ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION
In a parallel but independent initiative with major import for the education of physicians, the Accreditation Council for Graduate Medical Education (ACGME) introduced a set of six areas of general competency in 1999, with the expectation that each accredited program would ultimately "define the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate [competence]" (12). Further, the ACGME policy states that "the residency program must demonstrate that it has an effective plan for assessing resident performance throughout the program and for utilizing assessment to improve resident performance."
The six categoric areas include (12) (a) "patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health," (b) "medical knowledge about established and evolving biomedical, clinical, and cognate (eg, epidemiological and social-behavior) sciences and the application of this knowledge to patient care," (c) "practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care," (d) "interpersonal and communications skills that result in the effective information exchange and teaming with patients, their families, and other health professionals," (e) "professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population," and (f) "systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value."
It is instructive to compare the thinking of the ACGME with that of the IOM. Although the terminology and specific categorizations are different, these two sets of competencies find more overlap than not. Both agendas emphasize communication, patient-centered care, teamwork, evidence-based practice, improvements in care, and systems thinking. To the extent that residency programs successfully incorporate the ACGME competencies and evaluative criteria into their curricula, the agenda of the IOM will also be well served. However, the way that the ACGME competencies were originally introduced—that is, without much effective prologue—was unfortunate because it left many residency program directors in the position of thinking they had just received another unfunded mandate. Where was the time going to come from to teach the new competencies and who was responsible for the associated costs? These are still valid questions, although more than 6 years later it is evident that residency programs have found ways of optimistically coping by embedding the general competencies in the approach to their own practices.
CULTURAL DEVELOPMENT IN THE HEALTH PROFESSIONS
While the core competencies of the IOM and the general competencies of the ACGME were developed primarily for the purpose of shaping educational reform, they can also be viewed more generically as delineating a set of core values to guide how health care should be delivered and the behaviors and actions of the health care workforce. The competencies go beyond the kind of factual knowledge or skills that are typically tested by board certification or licensure examinations and speak more to how a health professional should practice than to what a health professional practices.
Viewed in this way, the respective competencies support a conceptual transition—that is, from looking at health education as a process primarily aimed at transferring a body of knowledge and skills from teachers to students who "acquire" these skills to looking at health education as a process that requires career-long learning about how to act personally and professionally and how to work best within complex systems to achieve the highest quality and outcomes for all stakeholders across the spectrum of people and elements in the system.
Facts and skills will never become obsolete but should be viewed as a necessary threshold condition for entering the arena of medical practice and not the end goal of education. Rather, assimilating the values that are implicitly defined by the IOM and ACGME into the culture of medical practice—that is, patient-centered care, respect for patient preferences, high levels of communication between stakeholders, systems thinking, high ethical standards, teamwork, use of evidence to shape practice, and objectivity in assessing and improving quality—is a higher goal that builds on the factual knowledge and practical experience collected by health professionals throughout their careers.
None of the values expressed in the IOM report on educational reform as a bridge to quality or in the ACGME general competencies is new to health care practice by any measure or to the current efforts of individual training programs. What is new and compelling is the knowledge that, when leaders in health education were given a mandate to plot educational reform to achieve better quality and outcomes, they focused on several overarching principles rather than trying to refine or expand curricula in more traditional ways, such as summarizing knowledge to be learned in a syllabus. The competencies represent a shift from a descriptive approach, which is focused on finite curricular elements, to an outcomes approach, which is focused on values. The ACGME calls its initiative (12) the "outcomes project."
The practical importance of realizing the values embedded in the competencies of the IOM and ACGME comes, in part, because every health care organization—from the physician's office to the medical center—takes on a unique culture on the basis of how it assimilates these and other values and manifests them in behaviors. Culture is elusive; it is an intangible quality that distinguishes institutions and systems from each other and is a major factor in either helping or impeding institutions in achieving their goals. Positive culture is the glue that holds institutions together in the face of stress and is the lubricant that allows institutions to get work done efficiently, without resolving every issue in minute detail. Positive culture in the health care delivery system amplifies resources, inflates morale, and is palpable to patients. Adverse culture is devastating and holds the system and institutions back—individuals clash, plans do not work out, and patient care suffers. An insightful aphorism holds that "culture eats strategy for lunch." When culture and strategy clash, strategy—even with all of the best intentions—generally loses.
Most health care organizations have mission statements and many also have vision statements that help define the pathway to achieving their missions. Less common are statements delineating overall institutional values or guiding principles for human resource management that serve as axioms for how people should be treated. The IOM and ACGME have helped provide blueprints for crafting value statements and guiding principles that individuals and institutions would be well served to consider.
In conclusion, the IOM and ACGME, in putting forth their new educational competencies, have actually done something beyond that. The IOM and ACGME have defined sets of values and behaviors that are probably more important as guiding principles for achieving higher quality and safer care in the long run than any specific fact-based educational curriculum could achieve. Now the question becomes, how best can the health care system capitalize on this work?
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FOOTNOTES |
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References |
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TOPINTRODUCTIONReferences |
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This article has been cited by other articles:
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  J. H. Thrall Education and Cultural Development of the Health Care Workforce * Part II. Opportunities for Nonprofessional Workers. Radiology, August 1, 2006; 240(2): 311 - 314. [Full Text] [PDF]
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