DOtOMENTRESUMEED 155 067Si 024 309AUTHORTITLEPUB DATENOTEEDRS PRICEDE - PDF document

1 DOtOMENT.RESUMEED- 155 067'Si 024 309AUT
DOtOMENT.RESUMEED- 155 067'Si 024 309AUTHORTITLE.PUB DATENOTEEDRS PRICEDESCRIPTORSABSTRACTThis paper describes a method fcr defining theuniverse of competencies expected ofa generaliniernist. This wasaccomplished by defining the nature of the medicalpractice,describing the internalliedicine content interms of subspecialtydivisions andgeneral areas ofcompetence, and defining a format fordesc;ibing competencies. The f9xmat for describingcompetehcies usedinvolved defining six categories of knowledge,skills, and attitudes:(1)knowledge,(2) skills'(technical and psychoSocial),(3) synthesis,(4) wanagement, (5) research, and (6) education. Includedare adnumber of suggested procedures and,examples highlighting how:procedures .can be incorporated into other. curricular efforts.(BA)Bashook, Philip:G.; And Others-:Defining a Universe of Expected Competencies: AMethodological Example for Internal Medicine.Mar 78.1-,.,16p.; Paper presented at the annual meeting of theAmerican Educational Research Association (Toronto;Canada, March 27-31, 1978).,\MF-30.,83 HC-$1.67 Plus Postage..4fC6urse Content; *Curriculum Development;GraduateMedical Education; Health Occupations Education;Higher Education; !Medical Education; *Medicine;.*Perfotmance Based Educationv Science Education***4!*******************************************************************'Reproductions supplied by EDRS are the best that can be madefrom the original document..********ii*************vo******************************4**********ig***** Defining a Universe of ExpectedCompetencieS:A Methodological Example for-InternalMedicineCDHILIP G. BASHOOK, LESLIE J.SANDLOW,LelLrJOHN W.NottEINHARD.--4Michael Reese School of HealthSciences'Educational Development Unit-.'z41.AERAOSESSION 19.22MARCH 29, 19784:65 -'6O5 p.m-An essential assumption inmostcriterion-referencedmethodology discussions is .that.there,exists a defined uni-'verse of expected competenciesor objectives to which thetest resultscan be generalized. .In curriculumdevelopmentthe issue is expressed interms of a written description ofthe program objectives. .FeW.disciplineshave these

2 .Thispaper describes an effort, followir
.Thispaper describes an effort, followirig the,traditional instruc--t.tional systems approach, to develdpa curriculumsdocumentforan.internal mediciner4sidency.Included are a numberof suggested procedures and exampleshighlighting how the.procedures can be Incorporated into othercurriculd'r efforts.US DEPARTMENT OF HEALTH,EDUCATION & WELFARENATIONAL INSTITUTEDFEDUCATIONTHISDOCUMENT HAS SEEN REPRO.OuCED EXACTLY AS RECEIVED FROMTHE PERSON OR ORGANIZATION ORIGIN-ATING IT POINTS OF VIEW OR OPINIONSSTATED 00 NOT NECESSARILY REPRE-SENT OFFICIAL NATIONAL INSTITUTE OFEDUCATION POSITION OR POLICY"PERMISSION TO REPRODUCE YHIS.MATERIAL HA$ BEEN GRANTED BYphri&shookTO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC) ANDUSERS OF THE ERIC SYSTEM2cI4 a"°AIL.'refining a Universe of ExpectedCompetencies,:A MethodologicalExample for Internal'Medicine.PHILIP G. BASHOOK,, LESLIE 1. SANDLOWJOHN W. REINHARDPHILIP G. BASHOOKMichael Reese SchoOl of'Health Sciences.Educational DevelopmentUnit530 E. 31st St:Chicago, Illinpis 60616Michael Reese School of Health Sciences.Educational Development UnitMUch has been said of late about criterionrefereffcedtesting. l)An essential assumption in most of thesetestmethodology discussions is that there existsa defined uni-,verse of expected competencies or objectives towhich the-test results can be generalized.In the health professionsthere are only a few fields.l.n_whichcurricula are suffiCient-ly definecLto- meet the-testing assumption(e.g., 2,3).Theassumption is even more tenuous whentechniques other'thancognitive tests are incorporated into theassessment brew.In assessing the clinipal competence ofa phipician, for ex-ample, simulated.patient encounters,observations of perform-ance, reports from peers and patients, and audits of patientrecords as well- as traditional cognitivetests, all require adefined universe to which s7pled performanceis to be referred.Viewed .from the perspective of curriculum development,the expected competencies of A health professionalare impliedbythe content of the selectedtextbooks and journal --arti*Nme-,the scheduling of precgptorships

3 and studentinvolvement inclinirat-traini
and studentinvolvement inclinirat-training experiences:Howe/et, curricular documentinaorporatingva written-description of expectedcompetenciesare extremely rare.\These documents would be the sameonesneeded for the testing assumption.'With the increased emphasis on edudationalaccountability,particularly in thehealth professions,many programs are'un-dertaking curriculum revisions which incorporate defining,ex=7-pected competencies.,The most difficult task in these effortsismdelineating the limits Of thd field.A typical approacti'in-vollPts classifying' content and performance into behavioralob-jectil'es for knowlpdge, skills, and ,attitudesconsistent with'the Taxonomies of educational Objectives. (4,-5,0,7Common text-,books in, the-health professions,particularly medicine, containthousands of pages crammed with content.Picture writing atleast-50 tehavioral, objectivesin the Magarian stylefor eachpage. 7)Having' completed such a task it is unlikelythe Olo-''jdctiveb would be more enlightening-than readingthe textbook,to say nbthing of the psychic energy consumed in theprocess.'3 -).s,In most health disciplineethe range of content .andskillsmAes'sucha classifiChtion nearly insurmountable.After many furtiv'eattempts.beginning with the taxonomicclassifications, we devised a methodology fordefiningtheUniverse of competencies expected ofa general,-internist.This paper describes that methodas part of a generalour-riculum development approach, and'providessome recommenda-tionsAfor its use in other disciplines.METHODSSetting,...ne Department of Medicine at MichaelReese Hospital andMedical Center and the Educational DevelopmentUnit of,the'School of Health Sciences formeda 6-member ad hoc 'committeecomposed of general. internists, sub-specialists in variousfields of Internal Medicirie; and educatorsto review the, ex-isting curriculurd of the general Internal Medicineresidency.The residency has been inexistence forover 50 years and in-volves_thiee years-of required and'electiverotations in themajor medical subspecialties and healthcare delivery areas(e,g., hospital, ambulatory care,emergency r

4 oom),..'Approxi-mately-3.0yesidtsiare ad
oom),..'Approxi-mately-3.0yesidtsiare admitted each year.Traditional resi-dency trainingmodsare used:there 'are patient care ro-tations in each of the medical-subspecialties; there.are caseconferences, grand rounds, chart rounds, and other formal con-iferences for learning patient careTrinciples andmedical con-.tent; and attending staff and fellows teach all resi.Oents, withSenior residents responsible for guiding thei?junforbounter-parts.The program has a reasonably good rephpation'in thecommunity of internists, havingover 40.0 atplicants,fot'the.30..first-year.spces.However, as with all long stand4ng residencyprograms, written curriculum descriptions-are' curaeri, at' best,and do not contain clear definitions'of expected competenciesfor -the residency.-,e%%-..0 .'ta?.,.,'ProceduresN4'.,t-,The committ:ee began in ,F'ebrua'ry 19T6 meeti,ng weekly.Since.the initial meetings,the working mode hasevolved into threeformats....'41,,,,Format. a.Competencies defined., as specific,to m9dicl.-subspecialties (i.e., hematology, cardiology, etc.)are ini-.:,,tially.defined by the respective subspecialty diltpion staff4'./with help from the chief meaicalresident,and an educator.Their efforts are reviewed and modified by-the compfittee withcontinuOus input from subspecialists'and gerieral ini'ernists.,'.-°The resulting documents are reviewed kiy'a group,,of.reWents-i'representative of each residency year anda.group Of-internists,..---' inThgeneral practice. .Finally, the 'documents are forW4rdedto.,,the departmentfor review, approval and adoption..'4A#I4Pdo84r"'I - 3Format b.In the general content and performanceareas(i.e., those ,clinical competenciesthat cross over specialtylines, oare,non-clinical) the committeegenerates descriptions of competence either by drawingupon the expertise inthe' committee ot by obtaining consultationfrom experts inthe specific'area (i.e., legal, psychiatry).The review andapproval process follows thesame 1steps as iit'Format a.Format c.Much^of the initial discussion concernedde-fining how to proceed with. theoverall task.Ustialiy,he com-mittee chairman, an educator,

5 would suggeSia format orstrat-egy_for t
would suggeSia format orstrat-egy_for the task or encourage othersto propose iaeas.Inevi-tabily, there wereifrustrating deadend discussions; but, as.thegroup developed., the committeehas asked the chairman t6iserve as recorder, returning to'gubsequent meetings withadraf.6 of what ha$ been discussed forfurther debate..The re-,sults of these effortswere not reviewed.by,others in the man-ner of formats.a and b; but they Provided tile Subspecialtyex-perts and reviewers a fraffiework for their activities.Of course,the use of the materials and definitionsserved as an informalreview process.The three'formats have been.intertwined.overthe year withformat c emphasized during the first sixto, nine months andformats 'a and b predominant at other times..1'A typical meetingbegins by reviewing the prior sessionand reporting on progressin working with/the subspecialties.Alongtwith group mainten-ance activities this takes,aboutlfive minutes. -The remainderof the meeting usually is devotedto discussing competencies inone subspecialty or one general area., It requiresbetween,fourand five sessions to review, revise, andagree upqh competen-cies for a subspecialty and between threeand six sessions forthe general areas..--At the outset the committee was wellaware that department-al acceptance of their work depends .upori educatingand perSuad-..'ing the staff about their activities and thepotential,benefits..Also, the committee appreciated the.sensitivenature of theirticiPate in defining therestobjectives could be interpre:t=efforts:They realizedtasking the.medical staff topar-ed as challenging the quality of t-ogr_axot_and specificallythe, teaching competence of the staff.Keeping these concernsin ,Mind the committee has beenvery careful. to mainfairl'a low'profile and let results perSuade the,stafY.RESULTSThe committee, agreed upon a five-phase approach 'toits"task, petty much following traditional instructionalsystems.methodology (8):I aa"4.71.Describe the expected.competenciesf4the,general internist completing the .MichaelReese Residency.A2. .tivelop.and implement an evaluation method-'ology to 'as

6 sess the program'and whetherres-.idents
sess the program'and whetherres-.idents at the end, of the'program achieve-Number 1.,v',3. ,Review the existing reside cy'program byas-sessing its potential to help residentsachieve Number 1.eP:.',.i..-./4.RecommendILId- implement-changes in the exist-,ing residency `program:_.5.Rey,ise expected competenciet, evaluation Meth-odology,,and'the reAidency program to incor-poiate new approaches,concepts orcoritingen-..l es in thg ttainixig of general internists,1s,Asof this writing, the. committee' has focused almott,ex-clugively,upon Phase 1, describing the expectedcompetencies.However, before discussing'the methodology devised for Phase1 a brief explanation of the thinking,for the other phpsesmaybe helpful.�---#,)1'.phase 2 - Evaluation Methodology:The Committee has ac-cepted the conceptcthat..evaluation of the residency should fo-cus primarily on two areas:the program impact upon resident'sperformance, and the quality of the teaching/learning activities,The presentevaluatiori plan builds upona conceptualization for..assessing clinical competence reported previously. (9)The ,con -.pt aSSumes,that intekactions with patients are the criticaliidents to be measur d in assessing the residents' performance.An. -evaluation design h.tion.We anticipate adoevaluation, approaches winot been selected for program evalua-ting one of the popular curriculumh appropriate ad'ustments toour needs.Phase-/3- Review Existing Residency Programs'Department staff and chiefs of subecialty divisions have,been_involved iri defining expected comp tencies.:.The plan is-to return sequentially' o each subspecialty division with the.agreed upon competencies and help the division staff review the.,present rotatipps.We anticipate most will'rise to the odCasion.M.111,p.a few Will. !4ethis,opportiriity.to_expand territory or.resourcesor add'thi`g experienceoto their fodder in fightingagairist educational Change.#Phase ARecommend and Implement Chanes...%,Consistent with-the committee's ,philosophy of a low profile,'- Aioaftmenda\tions Will be_ forwarded. "to departmental committees and-staff for akorom01 beforg i

7 mplementation.Whenelier possible-,., ,.-
mplementation.Whenelier possible-,., ,.-r,*61s (pilot testing will precede some of the 'approvalprocess toprovide practical results for staff,discusion;Implement-ing changes will follow thesame cooperative efforits describedfor Phase,3..Phase 5 - Revisions'Incorporating revisions in fanestablished program dependson the nature of the program governancea d the revisions.Clearly, we are assuming that efforts,tove thd departmenttake ownership of the_. curriculum plan showd facilitate futureprogram revisions...Describe Expected Competencies:- Phase 1.The committee has struggled with three issuesin defin-,.ing expected competencies:(1) Whattis the nature of the med-ical practice anticipated of graduates?(2) How to describethe content expected to be masteredin the residency?(3) }lbwto define and format the knowledge, skills,and attitudes ex.:.pected of internists?1.Nature'of the Medical Practice.The .simplest definition of the expected, practice.conditionsof our graduates is to say "he/she will practicemedicine just,like.the,medical staff at Michael Reese."Beginning with care-1'ful introspection and critical analysistofstereotypic aolleagueswe concluded that the "good" general internist trained in theMichael Reese Residency would'have the followingpractice condi-tipns:an.urban private or joint practice. witha hospitaI-based..,:focus, Primarily emplbyitg tertiary care'facilitiesand 'relyinglupon house staff for day-to-day inpatient care, develotAnga,...,'network4of subspecialty bonpultants with which the general'in-ternist easily communicates and when ,usedfor,patient keferralthe ihternast retainsresponsibility for`cobrdinating the p.a.\tient's gard, andhaving the capability of managiimostApatient*problems Including many of the uncommon diseaSes withminima]. con-sultation frot subspecialis6s.,. The committee deliberatedaboutthe avaiIa ility of specialized laboratory facilitiesand theinternistability to 'perform some of the less'commonprocedures:'They.conclu ed that each Practice setting willplacespecial de-f,_mands on 'th ,internist'4talents and to d' fine practiceemphAsis more ri idly w

8 ould not be helpful.Instead; the-committ
ould not be helpful.Instead; the-committeedecided tha .01e'inteinistd shdiud have learned in theflesidencyhow to Acqu re the additionaltalefifs through'continuingeducation..,.,..c.:,2: 'Description of Internal Medicine -ContentThe committee%e4lored alternative descriptions-.of the4whole.field WIntirnal Medicine,Of particular interest' were the--approaches taken by Aissand Vaneslow '010) and"the-American..'Boaid 9f,pdiatrids 4(11).q puring the commit'tee's work, the,Am-ericariBoard.of Internal Medicine published quidslines fortes-i4'ncyprOgrams.'(12)The committee realized that their initial,instincts about 010 importance Of subspecialty &Visionsalso-'applied.W/deseribing:the internists?' competpies.In7 z- 6 -..addition to describing competencies inall subspecialties, weidentified a number of generalareas which internists mustmas-ter that are not part of any subSpecialty.The precise levelof mastery was defined for each:General Areas of Competence1.Medico-16gal concepts andprocedures2.' Medical 'records and documentation.3.Governmental and public policies4..Medical Consultationr,.5.Health care delivery modalities andconcepts6.Office practice management....,7.Preventive ancommunity medicine8.e Public Healthoncepts..iRather than replicate the contentfrom textbooks, thecommittee concluded that describingthe depth andscope ofknowledge or peiformance in anarea could be accomplished by;indicating a reference (i.e.,-.book, monograph, pamphlet,orjournal article)the expected functidning ofa general internist.hereference need not covers the whole.,field or be the traditional.reference farthe subject; but itmust convey-the' sense of the.Subjectat the level expected forthe general internist.For-example, the Red Cell Manualwasrecommended forehematology becaUse Itaddresses the topics atthe approprikte level;'however, the pamphletdoes not desciibeeverything expected of. internists.The aitional.knowledge'and abilities are ddscribed by objectiliesistedundei.the sub-spe.,,...3.Definitions and Format for DescribingCompetencies.A major'obstacle to:curriculUm developmentcan be con-.structing a 'format t

9 o display the durriculumthat is simple t
o display the durriculumthat is simple tolase and does not distort'the.philosophicd1 foundationsof adiscipline. 'Beginning with the classi'cal divisionsof know-ledge, skills, and attitudes, we evolved sixcategories for(this curricular display:..1.Knowledge.2., 'Skills,iPa.Technical-skills..b.Psychosocial skills3.Synthesis4:Management5.Research.___.,___---6.Education.-fDefinitions for each are contained in Figure 1.,'A second major obstacle .can le stating curricularobjec-tives in a manner which communicates -thecontent while notcoMMittee_decided to use behaviorgiol es follow,ing Gran-4ivbobjeburdeningauthors or readers-with 1 ng boring lists.The0 st,71r/..lund's format.' A gene-tel objective is followed-bya series ofspecific objectives that refine the generalobjective, orfrodrveas examples of expected performance required to demonstratemastery of the generakl objective. '(13)Foi example, .internistsdhould-be able to:,:.,,-,.,.,I.Evaluate the quality of research studies.,,,-N,,.Critique the studies' statistifalNydlidi,-7(-level of basic' statistical procedures(.ANOVA).7/77,b.Analyze the appropriateness.of expertmental des-igns40including use of.controlgroups, sampling procedures,.and prospective.or retrospective datacollection. .`-.:,*,at the,X2,A,c.Deduce assumptions' either implied by the research.methods or in the study conclusions.d:Criticize potential implicationolfindings and.tonclusions in relationship to accepted medicalpractice:The third obstacle, possibly unique to disciplineswith,aheavy emphasis on problem solving tasks,, is-differentiatingbe-'tween activities expected to be performed under theguidance ofwhich shoadperformedwithouthelp.In medicine these limitsexperts orto referepce materials and activitiesare fuzzy, particularly between generalmedicine/and the sub-Specialty areas.The committee decided upon twomeans of clarifying'thelimits of expeqise,.Formanagement of disease, diagnosingpatient problemand general patient care, the competendiesare separated intothree categories:(1).performed totally byan internist;(2) performed by the internist but utilizing-consultative

10 support; and (3) performedby a consulta
support; and (3) performedby a consultant with-An internist coordinating overall patient care.For example,b4in Pulmonary Medicine, the'paneral internist (not subspecialistshould be able to diagnose Infectious pneumonias caused bypneumococcus, staphylococcps, common_gram negative bacteria,anaerobic bacteria and viruses butare not expected to obtaina diagnosis forlinfectious'pneumonias-When it requires a spe--cialized procedure such as bronchoscopy.Or, pulmonaiy infer-,tions should%1;e routinely managed by general internists, exceptif they occur in iMmunosuppressed 'patientsor are complicatedby respiratory failure., For these, the internistcan rely'on the initial and-subsequdnt support of acorisultant.Foredical knowledge the committee defined four categoripsof understanding:(1) aware that the entity exists end isassociated with a particular disease condition;(2) able td-de-frm the nattiral history of the disease'or.conditions, initialtreatment requirements,-clinical manifestations, important lab-9 i1 r-I--.8oratory findings.and associated clinical.condition;(3) able.-to describe the Currently accepted pathophysitilogicalmechan-isms; 4nd (4) able to recognize thehistopathplogy 'of the dis-ease or-condition.For'exampf&, forSome rheumatological dis-eases like Lofgreh's synd ome, Whi2plesDisease, heritochromato7sis and'nodtlar synovi%ti4the internist should be awareoftheir existence aneassc iatedcondit gns.On the other hand,an internist. should be a le to descr'e the pathyphysiology ofgout, rheumatoid arthritig,neuropath c arthopathy,among otherconditions.fkDISCUSSIONAs the' complexities of Our societykincrease, there is a'tendency to centralize decision-makingabodteducation andi,health care.Witness the increased federal influenceupOn'what was locally determined.medicalsChool admissions policies,curriculum'requirements and graduationconditions--.-Or, watchthe maneuvering for control of theHealth Systems Agencies in-tended to coordinate the federal infusionof money and ide sinto local health care establi.shments.The educatiOnalsearch community has followed'thesame pattern with near tot

11 aldependence on federal funding of proje
aldependence on federal funding of projectshaving the requisite.attached strings"and encumbtvances.°The curricular developmenteffort described here markedly depaftsfrom this trend.Thefqcus is:, one hospital's residency program;the personnel arethe existing hospital staff; and thecost is their time and-energy plus minimal secretarial support.Outside funds andinfluence have been nearlyjion-existent.Except to comply withaccrediting requirements, the methodologylwasinitiated to Meetpractical ndtds of the institution.'How can this experiencecontribute to other curricular efforts?,The.answer lies with twoactivities:develop-ment procedures which foster portrayingas accurately-as feas-ible the content to) be mastered in the''-resident!;' and strate-gies implemented to help 'the departmenttake ownership of thecurriculum. development process and iti'prOducts.loVFollowing Schwab's conception of The Practical(14), withWestbury's modifications 0.5,, the committeewas 'careful toqrtake--sure that the descriptions ofcompetencies reflected "thepat-tern, order, method, structure"rofInternal Medicine and be-'dome what Westbury calls the "syntax -in-use of Internal Med-icine.Searching for the 'demarcation boundaries withinthefieldNof Medicine'wasan important curriculum development pro,-cedure *e performed inlEhis prbgram.By Applying the "syntax-in-use" of our situation, a subspecialtyemphasisand refer-ences to define content limit t, we also enhanced the growthof departmental ownership.For example,, the deparent staffroutinely function in asubspecialty frame-of-refeFend&Andhave had little diffidulty incorporatingthe results into 'their tthinking.In fact, one division chiefhas already used-thedefined competencies of his di cipline asitheminimum accepta-ble entry level in screeningrospective fellows.:.tr.�4 ^..10 z_/19WsAnother contribution of thiscurricular effort wh ch'should have general application 'isthe classificationf'categories required.to defineexpected competencies,heterms; k owledge, skills,csynthesis,management, educationand reSear h have become convenienthandles for organizing1our

12 thinkiabbut curricula generally, andpart
thinkiabbut curricula generally, andparticularlyfor residenprogralpS.In our efforts at describinga gen-.eral surgesresidejcy, for example, We haVe used thecate-gories witut modilgication.,.A-Finally; the ,difficultiesin designating limits toex-NN\pertisewere addreSsed and resolved by expecting differentlevels of understanding Oruse of consultants.These levelsworked well'for all subspecialty areasand ,also the general-%--topics..,,/.1k..-..The committee.forMat and callingin of,experts for testi-mony about their field is not hew.One of the earliest com-ptehensive curriculum projects inmedicine at the Abraham Lin--coin School of Medicine,'Universityof Illinois 2) used thisapproach.Howevet, the efforts reported hatediffer =in thatthe/experts are intimatelyinvolved in the first stage of.gen-erafing the content without havingto submerge their parochialinterests.They freely express their IDiases inrepresentingtheir subspecialty and do not feelthey serve as a representa-tive in` creating a joint multidiscip/inarypackage.Theircc-advice stands accepted, in their disbiplineand only is chal-lengef 'whet) the expected competeriCiesmay not be ariate.,/for a*general internist's practice of medicine.Wepur-posely avoided discussing how the subspecialistshould teachthe needed abilities, in older.. te- circumventdisagreements onthe number of weeks'or months of rotationrequired in each sub:-specialty. 'Hopefully, that'issUe will be discussedin Phase 3.In thinking back on thiv.cur'riculum developmenteffort;.two feelings stand-out..The amount of tin., psychicenergy,and dedication required, to reach, this gbalmay explain why few-have attempted it.And, all, those wh16 encouraged itseffortor acted as nay-sayers while'sitting onthe sidelines,may -be',an important stimulus for perseverence.,The second dominant-feeling is frgstration.Each search of 'the curriculum devel-opment literature'for guidance found few guideposts.In thefew instances where constructive ideas:wereapparent,'the re-sources intmanpower and money anticipated for the tasksnegat-ed our considering their adoption.Hopefully, this paper canenc

13 ourage others to report their,curricular
ourage others to report their,curricular strugglesand con-tribute to defininga coherent direction in curriculum devel-opment for the health care professions.A.. 'h...//o REFERENCESr1.. Meskauskas, J.A.,EValuation modes forcriterion-referenced-testing:Views regardinq.mastery and standard setting.)Review.of EducationalResearch,.19,76, 46, 131-158..2.University of,1linois College ofMedicine.Curriculum ofthe Abraham Lincoln SchoolOf .Medicine of theUnivirsityof4Illindis College of Medidine,Chicago: 'Author, 1973.-3. LaDuca, A., Madigan,M.J., Grobman, H., Sajid,A., Risley,.M.E., and Giannini, G.Professional Performance;SituationModel for Health ProfessionsEducation:OccupatiRnal-Ther-apy. 'Center for Educational!Development, -University of.IllpiOis at the MedicalCenter, 1975.,.-*..,..4. _Bloom, B.S.(ed4. Taxonomy ofEducational Objectives',__,'Handbook I:Cognitive) Domain.New, York: David McKay Co.,..c,,1976.J.,I-1--B.S., and Masia,AB.B., Taxqndmy of'Handbook PI:Affective DoWiin:.Co., 196k..p.,.-415.KrAthwohl, D.R., Bloom,EducationalObjeci4v4sNew York:David M6Kayl6.,Harrow, A.J.A Taxonomy'.of the Psychomotor'Domain.:New-.rYork:DavidMcKay Co., 19121F,,,..,444.60e6e.F:Prepaing Objectivesfor Programed Instruction..,isco.:-FearonIpublisiAks, 19.621...P,3.8.. Baiiathy, B.H.Instructional. Systems.'Belmont, California:.Fearon Publishers, 1968.:,-.,,4t!,A4_7.MageSan.-9.BashOOk, P.G. A cionceptikal fritorkfor measuring clinical.4problem- solving.. Journal "of Mecal Education, 1976, .51,109-114.'.10.Hiss,' R.G.i and Van slow, N.A.Objectives of,a residencyin internal medicin :American HospitalMedical EducatorsJournal,, 1971" 4, 11'752-J.'_J."I-eh;-IBurg, F.D., BrowV.ee, R.:C.,)Wright,F: H.', Leuine.H.,,.Daeschner,, C,W., Vaughan,III,V.C.., and Anderson,J,A.:A 'method for defining compftincy,inpediatirics-Journal,r- of Aedical Education,' 1976,.51, 824-828.:.._,b --:/.....,2.American Board of Internal MOy.cEe.,tRepo4t of the .Committeeon Evaluation in .general 'Internal Meldicille.March1977........!..v.,.13.The Red Cell Manual:Seattle:Unlipisity of Washington*00'iPressic 1976.!, J:.I,.,-..,.iti14.G

14 ronlund, N.E.Stating Behavioral,Objecti/
ronlund, N.E.Stating Behavioral,Objecti/eS'for Classr9om..Iistruction.New York:The MacMilian,CoMpany,1970,0.,-°".12,,7 - 2 -a15.Schwab.,,g.J.The practical:A language for-curriculum.SchoolReview, 1969, 78, 1.-24.16.Westbury, Ian.-The character of a curriculum for,a "prac-tical" curriculum:Curriculum 4Theory-Network, 1972, 10,25-36:-111.13( INTERNAL MEDICINE RESIDENCYPROGRAMFigure 1:Definition of Concepts.'he resident coMpleting'the program in InternalMedicineshould 6114,.....ableto demonstrate:competemce--in the clinicalevaluation andmanagement of paeients,'anunderstanding andability to performresearch, and an interestand preparationfor continued learning.Specific.definitions forthese attri-butes are definedunder' the headings:knowledge, *skills,"synthesis, management,research, and education.1.KnowledgeKnowledge is definedas the ability to recall infor-Nation and comprehendimportant concepts.Medicalknowledge as used hererefers to understandingphysical:and psychosocialsystems and diseases.Foreach system,knowledge ofthe basicor common diseases whichoccuris essential.This includesan anders,tanding 'ofth'dgeneral diagnosticapproaches, the pathophysiologytthe' natural histoi-Y ofthe disease and effectsof inter-vention, and thetreatment options.Knowledge in thepsychosocial domain'inclmdesfamiliarity with basictheories of, personality (normaland abnormal), socidt-economic factors affectinghuman b,ehavior, and behavioralcharacteristics of patientsand families.R.Skills\Skills are defiedas the observable performance ofacquiredbehavi or.Medical skills have threecharacter-istics: reliabOity,efficiency (interms of both speedansd appropriateness),and completeness ofperformance,.N.,Two types of skillsare appOrent when considering medicalperformance:technical skills..r.equiringphysical actionsand verbal interactionwith the Patient;,andpsychosocialrequiring verbal and non-vrbalinteraction.A.Technical SkiLlsAPTechnical skills are demonstratedin data acquisitionand in careful applicationof treatments designedtoaffect desired outcomes forehe patieht..In datayacquisition, .the phySleianTerformsprocedu

15 res tradi.t-tonally classifiedas history
res tradi.t-tonally classifiedas history taking, physical examin-ation, and laboratoryprocedures.Obtaining relevanthistory is dependenton skill in selecting and postn-0.--,questions.The reliability of the datais,in turn,:affected by:how the paijent presents information0 2-/**--available froffrprio'r:or collateralsources, and, mostimportantly, therapport established betweenpatient,and physician.All of these'factOrs must'be consideredwhen measuring the,physician's reliability,efficiency,and completeness inhistory taking.Measuring perfor-mance'in physical examinationand laboratory proceduresis affected by similarconsiderations. Technical skillsapplied in treatingpatients are primdrilydemonstratedin the proper preparationand use of equipMent andpro-cedures involving physicalcontact with the patient.' PsychosocialSkillsPsychosocial skills includeunderstanding the indivislualpatient's behavior,establishing rapport and communi-cation with patients.Effective understanding ofpatientbehavior is demonstrated whena resident can accu,ratelydescribe the patient's behaviorand explain obviousunderlying causes..When rapport is establishedwith apatient, there should bea feeling of trust, openness,and comfort in the relationship,and' the patient shouldbe able toexpress his or her feelinge easily.Thecritical-,communication skills, inaddition to the techni-cal skills .involving verbalacquisition of data,are anability,to recognizenon verbal cues and maintain""rapportduring interactionswith the' patient.SynthesisSynthetis is defined as_theprocess of combining facts- (data)to form a complete -and coherentunderstanding of what is known.Medical synthesis is theprocess of collating data intoalist oflproblems eachat the highest level oT refinementconsistent with availableknowledge.The most refined state-ment of a proble1111 m isa diapbsis.Three elementsare key, in this process;recpgnition of datumor bollected data, which constitutediagnostic clues; juxta-position of these diagnosticclues with known disease,chae-aeteristics to identifydifferential diagnoses; andsystemicollection of additional-datato reach a

16 defiAltive,diagnosis.tr 3IV.ManagerdentM
defiAltive,diagnosis.tr 3IV.ManagerdentMedicalManagement is the coordinationand direction ofthe p'atient's healthcare,Its focus is uponteffectivelicombining knowledge,diagnosti,c and therapeutictechniques,medications, and healthcare resources, to attainan optimalhealth state for thepatient.There are six elementsin-volved in management:1)knowledge of the patient'sphysical,psychological, and environmentalsituation;2)knowledgeof health andpathologic states anddisease entities;3)knowledge of therapeutictechniques, includingeffective useof patient educati6nto aid thepafientin,understanding hisdisease, the effectsof therapy, and hisrole in themanager-.ment process; 4)synthesizing appl'opriateelements of patientdata into diagnoses.;5)applying and modifyingtherapeuticregimens to maximizethe effects of therapy,and 6) appro-priate use of-consultantsand various health careresources;(a, knowing who,when, and how to obtainconsultation,b.knowing how to evaluateand use consultativerecommen-dations).-V.Research'Research is definedas critical investigationor experi-mentation aimed at (he-discoveryof knowledge, validationorerevision of previousknowledgeand theories,establis.hingthe validity of previousfindings, or the practicalappli-cation of knowledge.Experience in thiiarea would providea fpundation for:1)assessing the quality ofresearchfindings, 2)appreciating the needto continually incorpor-ate new findings into the practiceof medicine, 3)'appre-ciating the importanceof participating inresearch, and 4)appreciating the need forongoing researchto expand medicalknowledge.7'4141.EducationContinuing educatioli is theprocess of continued learningfor acquisition anddevelopment of skills andknowledge.Continuing education helpsimprove and refine'presentskillsand knowledge (technical,psychosocial andmanagement, etc.).Coi-alouingeducation also includes'involvementwithin theteaching/learningprocess as an instructor.In this'capacitythe resident would beexpected to be ableto perform all ofthe following:didactic ,teaching, clinicalteaching, and\teaching as a therapeutictool in treeng patients (patienteducatib