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Competency-Based Training and the Competency Framework In THIEME 272 Special Article Competency-based Training and the Competency Framework in Gynecology and Obstetrics in Brazil Treinamento orientado por competência e a matriz de competências em ginecologia e obstetrícia no Brasil Gustavo Salata Romão1 Marcos Felipe Silva de Sá2 1 Department of Medicine, Universidade de Ribeirão Preto, Ribeirão Address for correspondence Gustavo Salata Romão, MD, PhD, Preto, SP, Brazil Universidade de Ribeirão Preto, Ribeirão Preto, SP, 14096-900, Brazil 2 Department of Gynecology and Obstetrics, Faculdade de Medicina (e-mail: [email protected]). de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil The main document included in this article - Boxes 1-16 - was prepared by the National Medical Residency Commission of Febrasgo. Members: Alberto Rev Bras Ginecol Obstet 2020;42(5):272–288. Zaconeta, Alberto Trapani Junior, Claudia Lourdes Soares Laranjeiras, Francisco José C dos Reis, Giovana da Gama Fortunato, Gustavo Salata Romão, Ionara Diniz Evangelista Santos Barcelos, Karen Cristina Abrão, Lia Cruz Vaz da Costa Damasio, Lucas Schreiner, Marcelo Luis Steiner, Maria da Conceição Ribeiro Simões, Mario Dias Correa Jr, Milena Bastos Brito, Raquel Autran Coelho, Sheldon Rodrigo Botogoski, Zsuzsanna Ilona Katalin de Jarmy Di Bella, and had the collaboration of Agnaldo Lopes da Silva Filho and Gabriel Costa Osanan. Although the idea of developing professional competency Acquisition and use of knowledge: although evidence- had been mentioned since the 1970s and 1980s,1,2 the term based medicine is the major source of reliable knowledge medical competency remained undefined until the 2000s, for clarifying clinical doubts, the tacit, heuristic, and recog- when a broad literature review was published with the aim nition-based knowledge is also greatly important for devel- to clarify its meaning.3 In 2002, the result of this study was oping clinical competencies. Personal experience with published in JAMA by Epstein and Hundert,3 and medical clinical cases remains a great source of cognitive learning competency was defined as “the habitual and judicious use of for physicians.3 communication, knowledge, technical skills, clinical reason- Integrative aspects of care: professional competency is ing, emotions, values, and reflection in daily practice for the not simply the demonstration of isolated clinical skills but benefit of the individual and the community to be served.” their integration. When observing the medical activity as a This made it clear how much the concept of competency whole, there is a difference between integrated technical differs from skill. The latter is used to designate the ability to skills and their isolated observation. A resident physician perform specific technical-cognitive acts and actions such as who evaluates the parturient according to the precepts of intrauterine device insertion, obstetric examination, deliv- the partogram and demonstrates technical ability to per- ery care maneuvers, and the communication of bad news. form delivery maneuvers at isolated times, may not provide The concept of competency is broader and includes the adequate care during delivery when the integration of these integration of knowledge, skills, and attitudes.3,4 Therefore, two skills is needed. According to Friedman et al,5 a medical competency is a multidimensional term and com- competent professional is able to think and act as a physi- prises a set of cognitive, technical, integrative, interpersonal, cian. Schon argues that professional competency is more and affective-moral domains, as well as mental habits.3 than the ability to solve clinical problems using shortcuts Some aspects concerning the subcomponents of medical and factual knowledge, but extends to the ability to deal competency based on the definition of Epstein and Hundert with uncertain, challenging situations and make decisions (2002)3 stand out: from a limited set of information.6 Coping with these received DOI https://doi.org/ Copyright © 2020 by Thieme Revinter April 30, 2019 10.1055/s-0040-1708887. Publicações Ltda, Rio de Janeiro, Brazil accepted ISSN 0100-7203. February 4, 2020 Competency-based Training and the Competency Framework in Gynecology and Obstetrics in Brazil Romão, Silva de Sá 273 situations requires the mobilization of scientific, clinical, Accreditation Council for Graduate Medical Education and humanistic expertise for guiding judgment and deci- (ACGME) developed the competency framework for under- sions.7 Stimulating reflection on the practice performed by graduate medical education in the United States (Outcome the resident physician through feedback from his or her Project), which was adopted as a reference for medical supervisor promotes the development of integrative skills education in that country in 2001.13,14 The National Accred- for the integration of knowledge and proper management of itation System of American medical schools was also restruc- uncertainties.3 tured based on these competencies (the Next Accreditation Interpersonal relationship and communication skills: System - NAS), and became effective in 2013.15 In the United the quality of the communication and relationship estab- Kingdom, the medical education reform had already begun lished between the physician and the patient interferes with in 1993, with publication of the ‘Tomorrow’s doctor’ docu- health status, recovery, control of chronic diseases and ment. This document was revised in 2002,16 2009,17 and treatment costs. Proper communication with patients favors 2018.18 The latter was called ‘Outcomes for graduates’,and a better understanding of their health conditions and a corresponds to the current competency framework for un- reduction in the degree of anxiety.8 The person-centered dergraduate medicine in the UK.18 These countries were the care is guided by qualified listening, response to their feel- first to require that residency programs were also compe- ings, and the inclusion of patients and their values in the tency driven.2 The certification exams for obtaining a spe- definition of the therapeutic plan. Teamwork skills are cialist title and professional license have also become guided critical for patient safety and most medical errors result by competency assessment.9,13,19 from failures in these skills.3 This change meant the transition from a knowledge-based Affective-moral dimensions: the evaluation of the affec- training system with exposure to specific content to a tive-moral domain is a difficult one because it involves competency-based system. Training based on the acquisition subjective characteristics, such as trust and professionalism. of knowledge presupposes a predefined duration of the Neurobiological studies indicate the affective component is discipline so that a certain content can be assimilated by central for judgment and decision making; hence, emotional all learners. Competency-based training, on the other hand, intelligence is a fundamental skill for medical practice.3 establishes levels of competencies (milestones) that must be Mental habits: professional competency requires mental acquired and demonstrated by learners so they can progress habits that promote attention, investigative curiosity, self- independently from their peers. Knowledge-based training awareness, and the initiative to recognize and correct one’s is more static and focused on disciplinary content, while own mistakes. Competent practitioners should be able to competency-based training is more dynamic, learner-cen- identify their degree of anxiety in the face of uncertainty and tered and requires greater flexibility in curricula and training assess how much their emotional state may interfere with programs. In knowledge-based training, the assessment clinical judgment. From this point of view, medical errors can process is performed at the end of each block, internship, result from overestimated security in the face of uncertain or discipline with the aim to check content assimilation situations.3 (“learning” assessment). In competency-based training, the Context: competency is context-dependent and involves assessment process is formative (“for learning” assessment), the professional’s personal skills, the patient’s character- with the aim to check skills acquired from observing resi- istics, the activity performed, the work environment and dents’ performance, which includes, in addition to knowl- the health system in which the activity is inserted.3 edge, the integration of procedural skills, communication The medical education reform movement has been a recur- and attitudinal components.20 The shift from knowledge- ring theme in scientific literature and the subject of several based to competency-based training has been considered the – proposals since the 1910 Flexner report.9 11 In the late 1990s, Flexnerian Revolution of the 21st century.9 the ‘To err is human’ report published by the Institute of Worldwide, medical education and competency-based Medicine (IOM)10 in the United States showed that even with training are advancing for improving patient safety and train- the 20th centuryadvances, healthcare in the country was not so ing physicians committed to professionalism, continuing edu- safe. Such a report was produced from results of two large cation, and social responsibility.2,11 In 2014, the ACGME, the studies and showed estimates of preventable deaths caused by American Board of Obstetrics and Gynecology (ABOG), and the medical errors between 44,000 and 98,000 a year in the United American Congress of Obstetricians
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