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Life Skills

April 25, 2014

The ACGME is a bit of a nag.  Established in 1981, the Accreditation Council for Graduate Medical Education is charged with regulating residencies, basically.  It was formed in response to some problems with variability in the quality of residency programs and lack of uniform standards.  This organization dithered and muttered, studied and interviewed, did surveys and wrote memos, and in 1999 came up with six “Core Competencies”, or domains of clinical competence that all graduating residents should have.  Here they are:

Patient Care:  Identify, respect, and care about patients’ differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.

Medical Knowledge:  Established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social behavioral) sciences and the application of knowledge to patient care.

Practice-Based Learning and Improvement:  Involves investigation and evaluation of one’s own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. 

Interpersonal and Communication Skills:  That result in effective information exchange and teaming with patients, their families and other health professionals.

Professionalism:  Commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.

Systems-Based Practice:  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.

The dithering continued, and 10 years later the ACGME started coming up with rules about how residency programs could get their residents to have all these competencies.  Residencies had to show they were teaching their residents this stuff in order to be accredited, i.e., in order to be a program anyone would want to go to.  Now the great minds in graduate medical education have decided they need a new accreditation system, which they called, in a recent Academic Medicine article: Next Accreditation System (NAS for short.  Catchy right?).  Always eager to reinvent the wheel, the ACGME did another survey and found that “program directors have expressed concern regarding the skill set among interns from different medical schools.”  Here are the four skills that these program directors agreed were most important: (

Professionalism –  essentially bioethics

Communication and interpersonal skills – fancy words for being able to function in a team

Practice-based learning and improvement – application of evidence in practice – Evidence Based Medicine

Systems-based practice – patient safety mostly.  Plus how to work the system effectively

Yep.  Same skills as the ones they found in 1999.  But take a closer look at these competencies.  These are not medical competencies.  They are life competencies.  You could apply this same skill set to any profession or business.  None of the skills listed, with the possible exception of evidence based medicine, is specific to physicians.  Just out of curiosity, I looked around the Harvard Business School website and found that, indeed, the business world has core competencies too.   Here they are: (

Harvard Graduate School of Education professor Helen Haste identifies these five competencies for the new millennium:

  1. Managing Ambiguity
  2. Agency and Responsibility
  3. Finding and Sustaining Community
  4. Managing Emotion
  5. Managing Technological Change

Hmm.  Let’s see.  Managing ambiguity.  As in, “Identify, respect, and care about patients’ differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with and educate patients; share decision making and management.”?  Agency and Responsibility.  Like “Commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.”?  Finding and sustaining community. Or, for instance, “…effective information exchange and teaming with patients, their families and other health professionals.”  Managing emotion. Well, you business people are  on your own there.  Managing Technological change.  EMR anyone?

So these are the sorts of things senior doctors thought it most important for junior doctors to know.  Not medicine.  Not technical skills.  Not drug dosages or differential diagnoses.  Not chemistry or physics.  Life skills.  Do we choose our medical students based on what’s most important to the senior doctors?  No.  We choose them based on their grades in science.  Are there any questions on the MCAT about how to communicate within a team?  No.  Do we really promote listening, communicating, understanding patient’s values, and educating them?  Not with all our intern’s noses in computers.  The ACGME core competencies, and the Next Accreditation System, are just words and regulations that have to be checked off.  They mean nothing.

  1. WOW. I am on an email list regarding improving diagnoses, and this really strikes me. Fabulous. It says a lot. To be honest, if we could conquer the above, you’d probably get rid of a number of complaints on medicine.

  2. Dana Seidl, MD permalink

    You have a wonderful blog. I hope it gets the exposure and links-to that it deserves.

    I’m glad you mentioned the ACGME as it gives me an opening to a wonderful quote (below) from one of our journals. Of all the frustrations in my years as a pseudo-academic, one of the worst was the daily evaluations of residents that you worked with. They were based, of course, on the six competencies of the ACGME. We all loathed doing these because they were essentially meaningless. Try evaluating a resident’s Systems-based Practice abilities after doing two cases with a resident. Likewise, try making a judgment on how they advocated disease prevention and healthy lifestyles as another example. And of course you ranked them on a one to three (or was it five?) scale, because what’s important? The numbers, dummy. The metrics!

    Like it or not, anesthesia education is part trade school, part academics, and part advanced life experiences, with a lot of suffering and sleep deprivation thrown in. A competent anesthesiologist doesn’t have to know how to do a whole lot of things, but the things they do need to know they have to do exceedingly well, quickly, and consistently. No one is an expert when they start, nor are they after three or more years of training. Still, stuff like this needs to looked at as are things like common sense, basic knowledge (not about tobacco amblyopia, please), and ability to get along at all hours with patients and colleagues without losing it or flipping out. To me, this is what it’s about — not some phony numbers about even more phony competencies.

    All of which leads me to my latest favorite quote, this one about educating residents: “The changes that need to be made in order to go from a time-based residency to a competency-based residency will be a noteworthy challenge. “Dr. X” has postulated that, “The transition will likely include intermediate hybrid frameworks containing time and process components as well as specific competency-based outcomes.” Got that? Gee, guys, you left out Six Sigma!

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