- Email: [email protected]
National curricula, certification and credentialing
t h e s u r g e o n 9 ( 2 0 1 1 ) S 1 0 eS 1 1
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
National curricula, certification and credentialing Richard H. Bell American Board of Surgery, Philadelphia, PA, USA
article info
abstract
Article history:
The education, certification, and credentialing of surgeons is undergoing change brought
Received 22 October 2010
about by public expectations and by reform within the profession. In the United States,
Accepted 3 November 2010
there is a clear trend towards standardization of education, as exemplified by the Surgical Council on Resident Education (SCORE) curriculum. There is an emerging effort to tie certification closely to the national curriculum. Finally, there is clarity emerging from the
Keywords:
curriculum development process about the expected operative skills of graduating surgical
Internship and residency
trainees, and this will ultimately drive the process by which surgeons are credentialed by
Education, medical, graduate
their hospitals or surgical centers. This period of change is being accompanied by
Certification
a demand for more assessment of trainees and for outcomes-based training and residency
Specialty boards
program accreditation.
Credentialing General surgery
ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
The past decade has seen heightened interest in the process and outcomes of surgical education in the United States. In the U.S., the responsibility for overseeing graduate medical education (the training between medical school and independent practice) is divided. Since 1981, the process of training and the structure of residency programs has been overseen by the Accreditation Council for Graduate Medical Education (ACGME), a non-profit, non-governmental entity which reviews and accredits residency programs through a system of Residency Review Committees (RRCs). There is an RRC for each of the 26 allopathic medical specialties including Surgery. The RRCs are made up of nominated specialists in the appropriate field and there is also a resident representative. RRCs review all of the residency programs in the United States through site visits and by review of an extensive dossier of information provided by the program. A range of judgments can be rendered, ranging from full accreditation for periods up to 5 years, to accreditation with citations that must be addressed, to probationary accreditation, to withdrawal of accreditation.
Approximately 10 years ago, the ACGME began a longterm project to move from the traditional time-based, apprenticeship model of graduate medical education to a system in which certain competencies were expected of all graduating residents. These competencies were defined in broad terms by the ACGME and really are not specific competencies, but rather competency domains (Table 1). The ACGME subsequently added sub-competencies in each of the six domains and the RRCs added language specific to their respective specialties. In July 2003, the ACGME began to require evidence that residency programs were incorporating teaching and assessment in the 6 domains of competency into their training. This was a difficult challenge for programs to meet, because their educational focus had largely been on medical knowledge and patient care and most programs had no formal instructional methods in professionalism or communication and no tools for assessing their residents in a systematic way. The competencies of systems-based practice and practice-based
E-mail address: [email protected]. 1479-666X/$ e see front matter ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.11.007
t h e s u r g e o n 9 ( 2 0 1 1 ) S 1 0 eS 1 1
Table 1 e The 6 domains of competency expected of all residency graduates in the U.S., as defined by the Accreditation Council of Graduate Medical Education (ACGME). Patient Care Medical Knowledge Professionalism Interpersonal Skills and Communication Systems-based Practice Practice-based Learning
learning were even more foreign to the residency environment. Nevertheless, programs began to embark on a different way of teaching and assessing, and the ACGME has created a sea change in thinking about residency education, shifting the focus away from the traditional end point of time under supervision to an end point of competence, assessed in a structured manner. Whereas accreditation of residency programs is the purview of the ACGME, the certification of individuals at the conclusion of surgical residency has been the responsibility of the American Board of Surgery (ABS), one of 24 specialty boards who collectively make up the American Board of Medical Specialties (ABMS). The ABS took on the mission of examining candidates at the end of their training (MCQ plus oral case-based examination ) and certifying that they had received satisfactory training and achieved an acceptable level of medical knowledge. Board certification is and always has been voluntary but the vast majority of hospitals require their staff to be board certified. In 2004, the ABS made a decision to involve itself more closely in the process of resident education. Before then, the ABS did not become involved with residents apart from an annual in-training medical knowledge examination (the ABSITE exam). However, the examination has always been viewed as formative e results are given to the residency program directors to give in turn to individual residents. In 2004, the ABS decided to involve itself more heavily in resident education and created a new General Surgery Residency Education Committee. This committee began to develop a defined curriculum for general surgery training. The ABS was concerned about the variability in training programs and about gaps in clinical experience exhibited by candidates presenting for certification, and so undertook the development of a national curriculum in an effort towards both standardization and improvement. In November 2004, representatives from 6 organizations e the ABS, the RRC for Surgery, the American College of Surgeons, the American Surgical Association, the Association of Program Directors in Surgery, and the Association for Surgical Education, met in Chicago and agreed to pursue 2 goals: (1) the development of a national competency-based curriculum in general surgery; (2) the creation of a national website to provide educational materials in support of the curriculum. The organizations agreed to provide funding towards the effort and a decision was made to hire a full-time
S11
surgeon to head up the effort. In 2006, I agreed to accept the position and moved from my position as Chair of Surgery at Northwestern University in Chicago to the ABS offices in Philadelphia. In November 2006, representatives of the 6 organizations met in Philadelphia and adopted a name for the group e the Surgical Council on Resident Education (SCORE). SCORE decided to develop its curriculum around the 6ACGME domains of competency and agreed that the patient care domain would be the starting point. SCORE defined the expected patient care competencies of graduating residents in 2 categories: (1) the care of diseases and conditions; (2) the performance of operations and procedures. We created subcategories in each of these areas that expressed the depth of knowledge and skills that we expected of the residency graduate On completion of the process, we had a total of nearly 700 topics in the patient care domain of the curriculum, divided into 28 categories. In early 2007, we began building the prototype of the SCORE website to deliver educational materials in support of the patient care topics. The goal was to identify available content that was of high quality and then license the materials for the website. Our overall goal was to assemble high-quality instructional materials (primarily text and video), assemble it to follow a curricular outline and organize it so that residents could easily find the content they were seeking. Currently, the website covers 266 topics e all of the “broad” diseases and all of the “essential-common” operations. Each topic is covered in a “module” on the website. A module consists of a set of performance objectives for that topic linked to the resources that address that objective, a set of links to the complete resources available for that topic, and a set of open-questions to be used for self-assessment or as the basis for teaching. The objectives and questions are original material written specifically for the SCORE curriculum. In the U.S., credentialing of individual surgeons to perform procedures is done by individual hospitals. The SCORE curriculum defines what procedural competencies are expected of graduating general surgery residents, and presumably these will over time come to be the procedures for which graduates of general surgery residency programs will be given privileges. If surgeons wish to apply for privileges to perform procedures that are above and beyond the expected complement of general surgical procedures, it may be necessary to demonstrate that he or she has done advanced training or, if applicable, obtain an attestation from the general surgery residency program that the surgeon has had sufficient experience with a procedure(s) in general surgical residency to be considered competent. In summary, in the U.S., general surgery is moving to a competency-based national curriculum which should serve to under pin certification and credentialing of surgeons.
Conflict of interest None declared.
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
National curricula, certification and credentialing Richard H. Bell American Board of Surgery, Philadelphia, PA, USA
article info
abstract
Article history:
The education, certification, and credentialing of surgeons is undergoing change brought
Received 22 October 2010
about by public expectations and by reform within the profession. In the United States,
Accepted 3 November 2010
there is a clear trend towards standardization of education, as exemplified by the Surgical Council on Resident Education (SCORE) curriculum. There is an emerging effort to tie certification closely to the national curriculum. Finally, there is clarity emerging from the
Keywords:
curriculum development process about the expected operative skills of graduating surgical
Internship and residency
trainees, and this will ultimately drive the process by which surgeons are credentialed by
Education, medical, graduate
their hospitals or surgical centers. This period of change is being accompanied by
Certification
a demand for more assessment of trainees and for outcomes-based training and residency
Specialty boards
program accreditation.
Credentialing General surgery
ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
The past decade has seen heightened interest in the process and outcomes of surgical education in the United States. In the U.S., the responsibility for overseeing graduate medical education (the training between medical school and independent practice) is divided. Since 1981, the process of training and the structure of residency programs has been overseen by the Accreditation Council for Graduate Medical Education (ACGME), a non-profit, non-governmental entity which reviews and accredits residency programs through a system of Residency Review Committees (RRCs). There is an RRC for each of the 26 allopathic medical specialties including Surgery. The RRCs are made up of nominated specialists in the appropriate field and there is also a resident representative. RRCs review all of the residency programs in the United States through site visits and by review of an extensive dossier of information provided by the program. A range of judgments can be rendered, ranging from full accreditation for periods up to 5 years, to accreditation with citations that must be addressed, to probationary accreditation, to withdrawal of accreditation.
Approximately 10 years ago, the ACGME began a longterm project to move from the traditional time-based, apprenticeship model of graduate medical education to a system in which certain competencies were expected of all graduating residents. These competencies were defined in broad terms by the ACGME and really are not specific competencies, but rather competency domains (Table 1). The ACGME subsequently added sub-competencies in each of the six domains and the RRCs added language specific to their respective specialties. In July 2003, the ACGME began to require evidence that residency programs were incorporating teaching and assessment in the 6 domains of competency into their training. This was a difficult challenge for programs to meet, because their educational focus had largely been on medical knowledge and patient care and most programs had no formal instructional methods in professionalism or communication and no tools for assessing their residents in a systematic way. The competencies of systems-based practice and practice-based
E-mail address: [email protected]. 1479-666X/$ e see front matter ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.11.007
t h e s u r g e o n 9 ( 2 0 1 1 ) S 1 0 eS 1 1
Table 1 e The 6 domains of competency expected of all residency graduates in the U.S., as defined by the Accreditation Council of Graduate Medical Education (ACGME). Patient Care Medical Knowledge Professionalism Interpersonal Skills and Communication Systems-based Practice Practice-based Learning
learning were even more foreign to the residency environment. Nevertheless, programs began to embark on a different way of teaching and assessing, and the ACGME has created a sea change in thinking about residency education, shifting the focus away from the traditional end point of time under supervision to an end point of competence, assessed in a structured manner. Whereas accreditation of residency programs is the purview of the ACGME, the certification of individuals at the conclusion of surgical residency has been the responsibility of the American Board of Surgery (ABS), one of 24 specialty boards who collectively make up the American Board of Medical Specialties (ABMS). The ABS took on the mission of examining candidates at the end of their training (MCQ plus oral case-based examination ) and certifying that they had received satisfactory training and achieved an acceptable level of medical knowledge. Board certification is and always has been voluntary but the vast majority of hospitals require their staff to be board certified. In 2004, the ABS made a decision to involve itself more closely in the process of resident education. Before then, the ABS did not become involved with residents apart from an annual in-training medical knowledge examination (the ABSITE exam). However, the examination has always been viewed as formative e results are given to the residency program directors to give in turn to individual residents. In 2004, the ABS decided to involve itself more heavily in resident education and created a new General Surgery Residency Education Committee. This committee began to develop a defined curriculum for general surgery training. The ABS was concerned about the variability in training programs and about gaps in clinical experience exhibited by candidates presenting for certification, and so undertook the development of a national curriculum in an effort towards both standardization and improvement. In November 2004, representatives from 6 organizations e the ABS, the RRC for Surgery, the American College of Surgeons, the American Surgical Association, the Association of Program Directors in Surgery, and the Association for Surgical Education, met in Chicago and agreed to pursue 2 goals: (1) the development of a national competency-based curriculum in general surgery; (2) the creation of a national website to provide educational materials in support of the curriculum. The organizations agreed to provide funding towards the effort and a decision was made to hire a full-time
S11
surgeon to head up the effort. In 2006, I agreed to accept the position and moved from my position as Chair of Surgery at Northwestern University in Chicago to the ABS offices in Philadelphia. In November 2006, representatives of the 6 organizations met in Philadelphia and adopted a name for the group e the Surgical Council on Resident Education (SCORE). SCORE decided to develop its curriculum around the 6ACGME domains of competency and agreed that the patient care domain would be the starting point. SCORE defined the expected patient care competencies of graduating residents in 2 categories: (1) the care of diseases and conditions; (2) the performance of operations and procedures. We created subcategories in each of these areas that expressed the depth of knowledge and skills that we expected of the residency graduate On completion of the process, we had a total of nearly 700 topics in the patient care domain of the curriculum, divided into 28 categories. In early 2007, we began building the prototype of the SCORE website to deliver educational materials in support of the patient care topics. The goal was to identify available content that was of high quality and then license the materials for the website. Our overall goal was to assemble high-quality instructional materials (primarily text and video), assemble it to follow a curricular outline and organize it so that residents could easily find the content they were seeking. Currently, the website covers 266 topics e all of the “broad” diseases and all of the “essential-common” operations. Each topic is covered in a “module” on the website. A module consists of a set of performance objectives for that topic linked to the resources that address that objective, a set of links to the complete resources available for that topic, and a set of open-questions to be used for self-assessment or as the basis for teaching. The objectives and questions are original material written specifically for the SCORE curriculum. In the U.S., credentialing of individual surgeons to perform procedures is done by individual hospitals. The SCORE curriculum defines what procedural competencies are expected of graduating general surgery residents, and presumably these will over time come to be the procedures for which graduates of general surgery residency programs will be given privileges. If surgeons wish to apply for privileges to perform procedures that are above and beyond the expected complement of general surgical procedures, it may be necessary to demonstrate that he or she has done advanced training or, if applicable, obtain an attestation from the general surgery residency program that the surgeon has had sufficient experience with a procedure(s) in general surgical residency to be considered competent. In summary, in the U.S., general surgery is moving to a competency-based national curriculum which should serve to under pin certification and credentialing of surgeons.
Conflict of interest None declared.