Careers in Hematology:
New ACGME Competencies: A Training Paradigm Shift?

Elaine Muchmore, M.D.

Dr. Muchmore is Professor of Clinical Medicine in the Cancer Biology Program at Rebecca and John Mooves UCSD Cancer Center, and Associate Chief of Staff for Education at VA San Diego.

The Accreditation Council for Graduate Medical Education (ACGME) approved new program requirements for the specialties of Internal Medicine at their September 2004 meeting that will become effective in July of 2005. The major change in the new standards is to require training programs to ensure that fellows have adequate competence in six areas: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Although programs started using global evaluation tools with these performance categories more than a year ago, most have delayed instituting specific learning objectives and formative evaluations because of confusion regarding the definition of "competence."

What is the ACGME asking? The global evaluation tools for fellows have traditionally included patient care and medical knowledge domains with attention to communication skills and professional behavior, so four of the newly-designated categories have already been introduced. Systems-based practice and practice-based learning and improvement were added to help trainees learn techniques to master current practice environments, in which monitoring quality of patient care and practicing quality improvement are required. Programs must incorporate these new areas and also move from global evaluation tools to those that demonstrate mastery. However, the ACGME has not defined benchmarks for competence. So, what has been asked is for programs to operationalize and standardize experiences and rating systems, with the goal of producing competent trainees able to integrate into, and improve, health care systems.

To take a specific example, how can a hematology/oncology fellow demonstrate competence in systems-based practice? Since all fellows must demonstrate awareness and responsiveness to the practice environment, the new task is to identify measurable activities that help fellows gain insights and, in turn, improve the system. The large number of measurable evidence-based decisions made by fellows in their collaborations with tiers of health professionals can be used both to evaluate their interactions and to improve specific system components.

Likewise, demonstration of competence in the second "new" category, practice-based learning and improvement, can be measured by tools that monitor the ability of fellows to navigate patient care practices in evidence-based formats. Once the metrics are developed, the next step, assisting fellows to learn from errors and to make corrections, easily follows.

The ACGME has indicated that programs need to develop one exercise, or learning objective, for each clinical rotation. A thoughtfully constructed objective can provide measurable information in most, or all six, required evaluation domains. The objective should be based on anticipated experiences for each rotation and make sense to both fellows and faculty. The learning objectives can be incorporated into materials evaluated during required biannual assessments, and, in fact, the quality of the training portfolio containing the completed exercises is an excellent measure of professionalism.

Thus, the new ACGME standards require institution of measurable learning objectives. It is important to recognize that the new standards do not represent a paradigm shift regarding accepted components of successful performance. Rather, participation and integration of fellows into the new process gives programs the opportunity to institute programmatic and practice enhancements, while achieving educational goals.

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