Note: This copy is for your personal non-commercial use only.

To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.

CONTROVERSIES

REVIEWS AND COMMENTARY

Competency-based Training: Accreditation as a Pathway to Wisdom1

Beverly P. Wood, MD
The challenge for professional education is how to teach the complex ensemble of analytic thinking, skillful practice, and wise judgment upon which each profession rests. William M. Sullivan (1)

Published online before print 10.1148/radiol.2522081999 Radiology 2009; 252:322323

1 From the Department of Radiology and Pediatrics, University of Southern California Keck School of Medicine, KAM 211, 1975 Zonal Ave, Los Angeles, CA 90033. Received November 12, 2008; revision requested December 18; revision received December 19; nal version accepted December 22. Address correspondence to the author (e-mail: bwood@usc.edu ).

Author stated no nancial relationship to disclose. See also the article by Gunderman in this issue. RSNA, 2009

ccreditation serves as a quality assurance process by which a teaching or practice institution or a learning and practice program is evaluated to determine if specic standards are met and to what degree these standards have been met. Conceptually, accreditation is designed to ensure an acceptable standard of learning for those who are being trained or taught. Physicians and the entire medical establishment are experiencing a change in issues of accountability to those whose health we guard and seek to improve. For medical education, accreditation of a teaching and learning program relies on evidence that it graduates physicians who are competent and demonstrates continuing and improving competence as keystones of the profession. By using this denition of accreditation, we must start with an agreement on the construct of physician competence and prociency and support further personal development of wisdom, expertise, and mastery. Accreditation, while dening and examining basic qualities and achievement, also encourages and stimulates further growth and innovation. Thus, it not only examines the current status of a program or an individual but also encourages and supports further learning and accomplishment. Without this important step, we are merely supporting and examining a basic learning program. Inevitably, concerns about patient safety, inappropriate variations in health care, and concerns of poor service or inadequate decision making have introduced questions about the competence

and practice of physicians and the adequate functioning of health care systems. Progressive skills, competence, prociency, and wisdom that develop over time are supported by personal activities of reection both during and after experiences. The competencies, therefore, foster and support the kind and level of reective practice that is part of necessary developmental learning and skill development of physicians. The excellent general description of professional competence by Epstein and Hundert (2) is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reection in daily practice for the benet of the individual and community being served. The competencies are remarkable for their universality in application to all of medicine, medical teaching, and continuous professional growth. Medical knowledge is an essential and fundamental basis of health care and physician performance. Knowledge is both foundational and integrative. That knowledge requires continual examination, reorganization, reestablishment, and expansion is not in question, although accurate measurement is difcult to achieve beyond examination of information and its interpretation. The steps that support and expand knowledge relate to its contextual development, critical analysis, and integration with what we already know and what we seek to explain. We initially experience data, which is of limited use without such personal interpretation and contextualization, a process that leads to its development as information of possible use. With experience, applica-

Discuss this article online at www.rsna.org/radiology/discuss

322

radiology.rsnajnls.org Radiology: Volume 252: Number 2August 2009

CONTROVERSIES: Accreditation as a Pathway to Wisdom

Wood

tion, and reection, it then becomes knowledge, which is now useful to us and applicable in the context in which we work. By following these necessary steps, we develop knowledge and nally wisdom. Polanyi (3) describes competence in terms of tacit knowledge rather than explicit knowledge. Tacit knowledge is that which we know but normally do not explain easily. The assessment of tacit knowledge, like clinical skills, is difcult because of its abstractness and individual variance. When we perform accreditation, we can examine information and foundational knowledge but cannot measure tacit knowledge and wisdom. This is not to say that we do not support their development and use. As a partner to medical knowledge, patient care is also an abstract concept, relating the application and integration of knowledge, its contextual interpretation, accumulated personal experience, and personal decision making. While reliable and valid practice performance measures are being developed, the assessment of critical skill modications and application of evidence-based medicine skills are difcult to measure in experts who have replaced deliberate steps of novices with their own shortcuts and modications. The more abstract measures of medical competencies previously thought to be intrinsic personal qualities of those who chose medicine as a career have become better dened. Both professionalism and interpersonal and communication skills are recognized as teachable, learnable, acquired, and able to be practiced at varying levels and with the advantage of personal growth and development possible; they are fundamentally measurable in terms of personal knowledge, skills, and attitudes. With the promise of quality improvement, these competencies do represent fundamental professional qualities of a physician and are personal qualities without which it is impossible to

successfully practice medicine. They represent the code of conduct of the profession and ones personal contribution to the profession. The concept of systems-based practice represents a change from and expansion on a tradition of physician autonomy, which reects the complexities of medical care and the necessity for accomplished teams of experts, advanced technology, communication, organized medicine, and facile access to information coalescing into a coordinated body to deliver good patient care. While the physician is a key member of the team, the collaboration necessary for care within the system of care is a key element of medicine. Recognizing and accommodating this competence is a way of working in the scaffold of medical care. Practice-based learning and improvement are anchored on the principle of lifelong learning. While the volume of information increases exponentially, its half-life accordingly shortens, and techniques and habits of attaining and maintaining medical knowledge become more complex, as does its management. At the same time, it is increasingly important for physicians to develop efcient ways to access needed information, critique the quality of evidence underpinning concepts, and combine it with their own existing concepts. Our learning is most often driven by clinical care and those clinical questions generated in the course of the practice of medicine, as well as areas in which we recognize a personal deciency, or private inquiry and concern. Learning in practice and then applying and modifying the learning in the context of situations we experience provide us with the chance to enhance our information store and through experimentation, application, and reection to improve both practice and general health care. Learning is inevitably tied to continuous change and improvement. We must practice medicine through

reection. Schon (4) has indicated that there are two key periods during which we reect on our practice. When confronted with a complexity or recognizing an unfamiliar problem, we initially must make a critical decision, reecting on the complexity in action. The process is not complete until we later reect on action to determine the appropriateness of our decision and dene further needs. This cycle of practice includes recognizing the unique nature of a problem, reaching a decision as reection in action, and reecting on action, in which the outcome of our thinking and new information are reviewed. While such reection is not necessary for each clinical problem encountered, as most use an automated response, the process does support considered action related to surprises or unexpected complexities that we encounter and recognize, thus building our experience and knowledge. Competence builds on fundamental knowledge, skills, and personal moral and ethical characteristics. That these characteristics can be measured in some way is fostered by accrediting groups, and that they can be gained and further developed requires curiosity, critical awareness, and self-assessment. The hope of accreditation is to support the further learning and accomplishment of individuals as they reach higher levels of experience and wisdom.

References
1. Sullivan WM. Work and integrity: the crisis and promise of professionalism in North America. 2nd ed. San Francisco, Calif: JosseyBass, 2005. 2. Epstein RM, Hundert EM. Dening and assessing professional competence. JAMA 2002; 287(2):226 235. 3. Polanyi M. Personal knowledge: towards a post-critical philosophy. Chicago, Ill: University of Chicago Press, 1974. 4. Schon DA. The reective practitioner. New York, NY: Basic Books, 1982.

Radiology: Volume 252: Number 2August 2009 radiology.rsnajnls.org

323