Medicine has wedded competency-based training for better or worse. Some would say medicine eluded this suitor longer than many professions, as it was in the 1980s that the United States Department of Education mandated educational outcome measures for accredited professions. For the first time, organized medicine had to define the various functions of a physician and the associated competencies. This initial step, building on the analogous Canadian effort and report published in 1996, culminated in the issuance of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Projects: General Competencies in 2000 (1). In addition to the six general competencies mandated for all medical subspecialties, psychiatry has specialty-specific competencies, requiring training in five psychotherapies (2, 3). Residencies are experiencing some consternation as they seek to implement competency-based training.
This Fall, the Psychiatry Residency Review Committee of the ACGME is revising program requirements. Educators in psychiatry are acutely aware, especially with regard to psychotherapy training (4), of the probabitlity that these revisions will further delineate how competencies will influence the daily training of psychiatrists. That competency-based training is here to stay is clear, but where will it lead us? In the spirit of supporting critical and creative thinking in the revision process, we offer the following comments.
First, the change to competency-based training will involve a broader cultural change. It is possible that the size of the cultural shift will be similar to that seen when the Flexner Report moved medical education from apprenticeship-based to curriculum-based training. For some time now, residency training has been based on fixed periods of time. If training is endured for a set period of time, matriculation follows. The system makes good in time, after one's dues are paid. The move to competency-based training may change this expectation in that the duration of training might be determined by the achievement of competencies as opposed to any other factor.
Hoff et al. (5) point out the inevitability of a change in culture. From the resident's perspective, matriculation is no longer guaranteed—competencies must be met. Residency training is not a matter of "paying one's dues," but rather a period of professional development by an adult learner. Improvements in working conditions and hours will naturally be expected. From the program perspective, the programs may now be held accountable for the competency of their graduates. They will need to give residents time for customized study and, if necessary, remediation. Preparing training portfolios, reviewing videotaped psychotherapy, taking standardized exams and more, all require time, which has fiscal implications. If the culture is to change, programs and their sponsoring institutions have to be willing to do so. In addition, resource-limited training programs will need extra support.
Second, competency should be understood within a developmental framework. One dictionary defines competent as "properly or sufficiently qualified, capable" (3rd edition, The American Heritage College Dictionary), suggesting a dichotomy as opposed to a continuum of ability. We might hope for more. In particular, we hope that our graduates will continue to grow and develop in their knowledge and skills and readiness to learn from clinical experiences.
In this issue, former Editor Paul Mohl describes, in a letter to the Editor, the 1998 formulation by the American Association of Directors of Psychiatric Residency Training and the Association of Academic Psychiatrists of skill competency as reaching "a position to assume full responsibility for one's continued growth and development" of that skill. This developmental framework is consonant with these organizations' endorsement of residency as the beginning of life-long learning. Similarly, at the medical school level, the curriculum can no longer accommodate the volume of medical knowledge, and a high priority is now placed on training medical students how to teach themselves so they may continue to do so in the future. The necessity of this is well illustrated by the fact that the majority of the currently prescribed psychiatric medications have only recently become available.
Most important to the developmental perspective on competency is residents' open attitude toward inquiry and critique of their thinking processes and practices. In our experiences, faculty members are often reluctant to confront residents when this attitude is wanting. Nevertheless, one-on-one interaction with faculty is probably the most effective context for modeling and assessing this attitude. Self-directed learning must be accompanied by self-assessment, and faculty should be given adequate training and time to teach this.
Third, psychiatric educators should guard against "teaching to the test" and, in so doing, forsake the most sophisticated skills of a physician. Many are familiar with the story about the man looking for his keys under the street lamp. Although he lost them down the block, he is looking where there is light. Measuring competency where the keys are won't be easy, especially in psychiatry, where much of the learning involves emotional and interpersonal aspects. For example, how may we assess a resident's careful management of countertransference toward a patient with borderline personality disorder and an erotic transference? In a case with multiple comorbidities, how would we know if a resident has mastered the subtle interviewing techniques needed to parse out the influences on mood of major depression, substance abuse, hepatitis C infection, and interferon therapy? While multiple-choice questions following a case vignette might be readily standardized and easily scored, they are not necessarily the most valid way to assess a resident's judgment and behavior in such circumstances.
If residents aren't observed with patients, some keys may be missed. This underscores Michael Whitcomb's (6) admonition that we not limit evaluations of residents to "structured and largely artificial settings." Faculty must take better advantage of naturalistic observation and evaluation of daily clinical work (6). One might note that psychotherapy supervision has been conducted for years without a supervisor ever directly observing residents' work. Today, however, competence measures will have to include the observed, despite its logistical challenges.
Of concern are the negative effects of residents or educators limiting their focus to the material that is tested. Every test comes with the implicit message that "this is what you need to know." To counterbalance this, the test must not be an end point alone, but should also stimulate further learning. In employment vernacular, the test is part of continuous quality improvement. The related challenge is to further develop tests that validly and reliably assess knowledge, attitudes, and skills in each of the competency areas.
One further implication of the decision to implement competency-based training is that curriculum planning becomes a technical undertaking and a systematic process of educational planning. This process is purposive, with the setting of agreed goals, which in turn are measured by the extent to which they have been achieved. At risk is a loss of attention to curriculum planning, which promotes reflection, questioning of the status quo, and student choice of educational processes. In much of medicine evidence-based practices are yet to be defined, and in these situations we need to have trained physicians to go beyond technically prescribed skills and seek creative solutions, while exercising common sense and precaution.
This is an exciting and challenging time as we learn how to define, implement, and measure competency-based training in psychiatry. As we respond to the profession-wide mandate to do so and to make systemic changes, we must also proactively evaluate both the positive and negative consequences of implementing competency-based training on our educational programs and outcomes.