Structured curricula and curriculum development in ophthalmology residency.

There has been a shift in graduate medical education (GME) from the traditional "apprenticeship" model to a more curriculum-based and competency driven model. Reflecting a global trend towards residency education reform, the International Council of Ophthalmology (ICO) introduced a resident and specialist curriculum and several live educational programs to promote standardization and more effective GME and continuing professional training. Implementation of these educational innovations will require efforts by local educator champions; modification and customization of teaching and assessing tools to the local learning environment; alignment of the implementation blueprint with available resources; and creation of accountability and sustainability mechanisms to insure long-term viability of the educational reforms. An ultimate goal of the ICO curriculum is to allow real world testing and modification so that the ideas generated in one part of the world might be applicable and generalizable in other areas. We aim to describe the Accreditation Council of Graduate Medical Education (ACGME) competencies in the United States (US) and ICO curriculum, as well as to provide a step-by-step plan for implementation of an ophthalmology residency curriculum.

BACKGROUND

New challenges and dramatic changes in the modern healthcare environment have driven the evolution of the role of graduate medical education (GME) in the United States (US),1 as well as throughout the world. Traditionally, the “apprenticeship model” has been the mainstay of GME in which an experienced faculty “master and mentor” educates, supervises, and guides the trainee or apprentice2 through an experiential learning process typically lasting years at a time. Although this apprenticeship model has served medical education well in the past, it has several limitations in today's modern healthcare delivery setting for several reasons.

The traditional model is susceptible to wide variability and lacks standardization across the range of performance among programs and individuals. The development of standardized program accreditation in the US by the Accreditation Council of Graduate Medical Education (ACGME) and increased documentation and performance criteria for individual board certification by subspecialty boards such as the American Board of Ophthalmology (ABO) have reduced the inherent variability and unpredictability of the traditional apprenticeship process. Unfortunately, the accreditation and certification processes are high-stake decisions that result in a “yes or no” final outcome, and there is a need for ongoing performance evaluation, that is lower stake, formative, and continuous rather than simply a single high-stake and summative outcome. Furthermore, the traditional model overemphasized the acquisition of medical knowledge as the overriding competency goal and overlooked other important but critical competencies including professionalism, system-based practice, communication and interpersonal skills, and practice-based learning.3 Accrediting (e.g. ACGME) and certifying (e.g. ABO) bodies have also faced mounting pressure from external stakeholders in the healthcare system (including the government, third party payers, and the public) to provide additional proof of both quality and competency in GME. This need for a transformation of GME from the traditional apprenticeship model to a more comprehensive, structured, competency-based education model has steadily gained acceptance and momentum amongst educators in GME.23

While the examples provided above refer to the US, the formalized effort to provide a more standardized training experience with well-defined objectives and competencies is mirrored globally and is actually only one of many others around the world. Numerous other international bodies are leading the shift from a traditional apprenticeship towards competency-based education, such as CanMEDS of the Royal College of Physicians and Surgeons of Canada. Given the international trend towards these changes in residency education, the purpose of our paper is two-fold: First, we aim to describe the ACGME competencies in the US with a focus on ophthalmology, as well as to describe the International Council of Ophthalmology (ICO) residency curriculum. Secondly, we will provide a sample blueprint that programs can develop and use as part of a stepwise program for implementation.

DEVELOPMENT OF THE ACGME COMPETENCIES

Three major advocates for the change in medical education were the public, the market, and the government.145 With increasing healthcare costs and the maturity of managed care, many players from the market joined the call for reform in the education area and started demanding that physicians know more than simply the science of medicine. These external stakeholders are now demanding that proof of competency include practice-based learning and systems-based care as well as other nonmedical knowledge domains (e.g. application of business principles, cost control, quality improvement projects, and utilization review). Furthermore, with the escalation of healthcare costs, the government has increased its regulatory role in medical practice and in the oversight and funding of GME.1

Likewise, the general public (through various patient advocacy groups) has raised its voice for change in the new medical education model. As modern healthcare consumers are becoming more health literate, increasingly educated about diseases, and more directly involved in their own healthcare; they have come to expect more responsibility, accountability, and proof of quality from their physicians. Furthermore, many professional certifying and credentialing organizations and boards are ultimately responsible not to physicians per se but to the public as their main constituency. Thus, certifying boards (e.g. ABO) have a primary responsibility and interest in protecting the public. Finally, graduating physicians in the US modern marketplace may find that future employers or hospital credentialing staff are demanding more evidence of competence beyond areas emphasized in the traditional model (e.g. compliance with medical documentation requirements, professionalism, communication skills and bedside manner, teamwork, and interpersonal skills). In response to the growing calls for reform in GME, the ACGME in the US proposed six core competencies beginning in the late 1990s.1 These competencies were developed with multisource input from across the spectrum of healthcare.167891011 The ACGME process included an extensive review of published curricula, reports, educational literature, surveys, and interviews and direct consultation with key stakeholders (e.g. government, corporate chief executives, public and private foundations, presidents of universities, residency review committees, focus groups of residents, program directors, practicing physicians, the public, and allied health personnel). The six ACGME competencies are listed below:

Patient care

Medical knowledge

Practice-based learning and improvement

Interpersonal communication skills

Professionalism

System-based practice.

The six competencies from the ACGME represented an initial step in the long-term development of educational outcome assessments and ultimately the development of a new accreditation process (i.e. the Next Accreditation System (NAS)). These competencies were incorporated in July 2002 into the ACGME Institutional Requirements and Program Requirements, and they established standards and common nomenclature that now facilitate communication and development across specialties and programs.1

ACGME “NOTABLE PRACTICES”

One outcome of the ACGME process has been the development of various notable practices, which are processes that a review committee deems worthy of notice and are shared through the ACGME website or other ACGME publications to provide additional resources for resident education.12 These include: (1) Model curricula, (2) faculty development resources, (3) assessment system, (4) competency assessment tools, (5) semiannual resident performance review, and (6) system-based practice.1

Some examples of ACGME notable practices for ophthalmology include the ‘Iowa Ophthalmology Wet Laboratory (OWL) curriculum for Teaching and Assessing Surgical Competency’;13 A Curriculum to Teach Ethics to Residents in an Outpatient Setting;14 and the ICO curriculum.15

The Iowa OWL curriculum described the implementation matrix for an OWL curriculum including written learning objectives, direct faculty oversight and mentoring, and pre- and posttests. The pretest defines the educational gap present, while the posttest documents the closure of the gap. As part of the feedback mechanisms, the Iowa OWL curriculum employs the Schon reflection model, which includes a “reflection on action, a reflection in action, and knowledge in action.” This reflection model encourages self-directed improvement, enhanced learner understanding, and self-motivation for learning.16 Furthermore, the curriculum mandates prerequisite reading material before entering the laboratory and emphasizes the Ericsson deliberate practice model in which expertise is achieved by deliberate and sustained practice. Purposeful repetition, analysis of improved performance over time, and further technique refinements are incorporated into the model.13 The documentation of performance achievement includes a criterion-reference rating form (i.e. Dreyfus model scoring rubric). Learners are expected to move through various stages of expertise in the Dreyfus model (i.e. novice, beginner, advanced beginner, proficient-competent, and expert). Using the Dreyfus model as the basis for the scoring rubric permits formative, lower stake feedback to be delivered to residents while providing an opportunity to improve in specific areas of deficiency. It also includes specific behavioral anchors to reinforce accountable and realistic metrics for change over time.1317

Another model curriculum published by the ACGME is Pach's ‘A Curriculum to Teach Ethics to Residents in an Outpatient Setting’.14 This curriculum was developed to address a perceived deficiency in the traditional teaching of ethics It specifically incorporates the perspective of the patient on disease; the role of the physician in the physician-patient relationship; and the purpose, potential conflicts, and personal growth of each physician in medicine. The ethics curriculum is divided into five sections as follows:14

The patient's perception of the disease process

The role of the physician in the restoration of health

The exploration of the individual physician's desires, motives, and talents and the development of an individual sense of purpose in medicine

Examining potential conflicts in the physician's sense of purpose and obligations

Personal growth and development in order for one to be a more effective physician, leader, and teacher.

The specific goals of this ethics curriculum include imparting to the resident the importance of looking at the patient as a whole person; restoring health by developing a relationship that allows doubts, worries, and fears to surface and to be addressed; and an anonymous self-assessment questionnaire given before and after the completion of the course to measure a change in the physician's personal views. Thus, the purpose of this curriculum is for the physician to be aware of different ethical issues and to stimulate personal thoughts and conclusions.14

The new ACGME mandate has also spurred the development of new and unique teaching resources such as the website, www.EyeRounds.org.18 This educational website includes case vignettes for teaching and assessing the ACGME competencies. Residents also have the opportunity to learn about specific competencies application through the development, production, and dissemination of content (i.e. “residents as teachers”).

ICO

The developments at the ACGME level in the US have had similar counterparts in Europe, Asia, South America, and worldwide such as the ICO curriculum. The ICO curriculum outlines three levels of supervised ophthalmic training: Basic, standard, and advanced. Each level includes both cognitive and technical skills.19 The ICO curriculum eventually aims to introduce new educational concepts for a modern curriculum outlining aspects of teaching and learning not defined in the traditional curriculum, and it hopes to serve as a template for local modifications that would include duration, length, timing, and frequency of training; who will be teaching, learning, and assessing the learning and teaching; and various teaching and assessment methods.19

A second ICO task force has updated the initial ICO curriculum by prioritizing the content and creating a fourth level (very advanced) used for defining fellowship-trained subspecialists.15 Ultimately, the standardized ICO curriculum will act as a foundation for the development of clear milestones of progression, thus serving as benchmarks for gauging performance and progress.19

The ICO has also developed numerous additional aides for training. In 2004, the ICO initiated a series of “Teaching the Teachers” (TTT) programs to promote and develop more effective methods of continuing professional development and training for a global audience.20 The ICO TTT initiative specifically included different methods, assessment, and curricula as part of its goal in creating a worldwide guideline for ophthalmic education in a live audience format, led by experienced international educators in a smaller venue typically connected with a regional or national eye meeting. In addition, the ICO has introduced an interactive online education starting as the World Ophthalmology Residency Development (WORD) and later becoming the Center for Ophthalmic Educators (COE), offering many educational tools for teachers of residents, medical students, subspecialty fellows, practicing ophthalmologists, and other allied eye care personnel. The ICO has expanded its curricular activities by creating and publishing a series of Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR) to teach and assess surgical competency (e.g. phacoemulsification, extracapsular cataract extraction, and small incision cataract surgery). It has also created web-based teaching modules and virtually mentored courses that offer aspiring ophthalmic educators tips and strategies about how to become a more effective teacher and how to leverage and utilize information technology platforms and e-learning activities to more effectively teach inside and outside of the traditional classroom, clinic, or operating room environments. The TTT program in conjunction with the ICO curriculum has thus created the opportunity for live venue and face-to-face discussions about adaptable teaching methods for ophthalmic educators around the world.20

Numerous international bodies have accepted the ICO curriculum, hopefully paving the way towards an international standard of training. For instance, recently the European Board of Ophthalmology (EBO) accepted the ICO Resident-Specialist Curriculum as the scaffold for training a specialist of ophthalmology in Europe. The ACGME in the US also has recognized the ICO curriculum as a ‘Notable Practice’ and furthermore worldwide it has been translated into Spanish, Mandarin, Portuguese, and French. The ICO curriculum thus creates an educational process standard that allows local educators to customize content. These standards remain a dynamic process and should be considered aspirational guidelines that could be modified as needed. It is designed to be a living work in progress and should be modified and revised to meet local needs.19 Thus, providing tools to educators to become better teachers ideally leads to better trained professionals and ophthalmologists around the world, and ultimately better patient care.

IMPLEMENTATION

While documents such as the ICO curriculum are available to aid with standardizing educational curricula, implementation of the competencies is the next step. We recommend that programs should develop and use the following as part of a stepwise program for implementation:1

Written goals and objectives and a specific curricula for teaching the competencies

Different evaluation tools (“the tool box”) to assess resident competence across multiple domains of competence

Valid and reliable tools and an iterative process where better tools are improved while poorer tools are discarded

A process to provide evidence showing the use of evaluation data in assessing the competencies over time

Educational outcome measures demonstrating overall program improvement and linkage to measures of importance to the external stakeholders (e.g. patient satisfaction surveys, quality metrics, and cost comparisons).

For programs interested in getting started we recommend the following stepwise approach:

Step 1: Blueprint—Define What Needs to be Tested

The objectives, curriculum, and assessment strategies must be defined at the onset, “piggy-backed” on existing curriculum, be adapted to meet the needs of the ACGME competencies, and should take into account the prioritization of content, a formal needs assessment, and the requirements of learners.

Step 2: Implementation of the Blueprint and Development and Usage of the Tools

It is important to not reinvent the wheel, and many organizations have devoted effort and time to developing free or low cost resources for getting started. A recommended starter toolbox is described below:2122232425

Patient care - objective structured clinical exam (OSCE) and patient surveys

Medical knowledge - written and oral exams

Practice-based learning - record review, chart audit, and portfolios

Interpersonal skills - OSCE, direct observation, and patient surveys

Professionalism - OSCE and 360 degree global ratings

System-based practice - 360 degree global ratings

*Surgery - OSCE, video review, and portfolio.

Step 3: Testing the Curriculum and Teaching/Assessment Tools in the Real World

One aspirational goal for both the ICO curriculum and the tool box of teaching and assessment tools is to allow real world testing and modification so that the ideas generated in one part of the world might be applicable and generalizable in other areas. Although standardization is the key goal, customization is a requirement for implementation across areas with variable access and limited or different resources.

FUTURE

In 2008, the ACGME unveiled the start of the next generation of accreditation in the US known as the Milestones Project and the NAS.26 Under the NAS, ACGME will accredit US residency programs and systematically track steady resident progress in the common and specialty-specific milestones. The objectives of the NAS are as follows:

Foster education innovation

Reward program and individual excellence

Require less frequent revision of standards

Create an infrastructure for continuous rather than episodic accreditation

Require less frequent but more rigorous self-study site visits for all programs

Concentrate on “problem programs” to rapidly enhance performance and outcomes.272829

In order to achieve these objectives, the ACGME plans on incorporating the Milestone Project into their implementation. The Milestone Project is defined as “specific behaviors, attitudes, or outcomes in the general competency domains to be demonstrated by residents by a particular point in residency.” The ACGME will be implementing the NAS in phases, with ophthalmology implementation occurring in July 2014. The ultimate goal of the ACGME is to demonstrate objective evidence of effectiveness of NAS competency-based education to the public and external stakeholders, including government and nongovernment organizations and patient safety groups. As ACGME rapidly moves toward NAS, it will hopefully reduce the burden of compliance with accreditation requirements, but still produces innovative, meaningful, and continuous benchmark outcome data.26

SUMMARY

There has been a clear shift in GME worldwide from the “apprenticeship” model to a more curriculum-based and competency driven model. The ACGME competencies and the ICO curriculum are just two examples of the response of educational organizations to the call for reform and innovation by internal and external stakeholders. Implementation of these educational innovations will require effort by local educator champions; modification and customization of teaching and assessing tools to the local learning environment; alignment of the implementation blueprint with available resources; and creation of accountability and sustainability mechanisms to insure long-term viability of the educational reforms.