Over the past decade, concerns have increased that young physicians are less prepared to meet society's perceived health care needs in the 21st century (1). To meet these needs, physicians must attend to a broader concept of providing health care, which extends beyond the goal of restoring health compromised by illness (1—3). The primary purpose of medical education is to produce physicians capable of meeting these societal expectations while providing excellent medical care.
To identify the attributes required to meet these needs, the Association of American Medical Colleges (AAMC) undertook the Medical School Objectives Project (MSOP) (1,4). The MSOP conducted a national survey of medical student deans and faculties to identify the attributes necessary to reach this goal. From the survey, four attributes were identified; namely, physicians must be altruistic, knowledgeable, skillful, and dutiful if they are to meet the 21st-century definition of the complete physician (1). On the basis of these results, the AAMC challenged medical schools to develop their curricula using these four primary attributes as a framework for the entire medical education experience.
Postgraduate training programs must also assume greater responsibility for defining the knowledge, skills, attitudes, and values necessary for training physicians who are competent to practice medicine. During the past decade, many medical specialties have attempted to define physician competencies (5—12). The first step in developing a consensus regarding the core competencies requires a shared definition of competency. The American College of Preventive Medicine has defined competency as "the ability to perform a complex task or function" (9,10). Additionally, a competency should specify outcomes, provide provisional predictors of competent professional performance, and clarify educational goals for trainees before training is initiated (10). Training also must make use of competency-based professional education models, in which the curriculum is directly related to the ultimate goal of training the individual for the specialized professional role, instructional or learning objectives are identified, and educational outcomes related to these objectives are both observable and measurable (9).
Although medical schools and residency training programs have long endeavored to develop educational programs that are competency based, the Outcome Project of the Accreditation Council for Graduate Medical Education (ACGME) recently increased the urgency of this effort for training programs by requiring that Residency Review Committees (RRC) incorporate general competencies into their requirements. In 1999, the ACGME mandated "identification of general competencies" and identified six areas of competency that all residency training programs must address (13). These areas are patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (13).
In response, the Psychiatry RRC implemented new program requirements for child and adolescent psychiatry training programs effective January 1, 2001. Programs are now required to develop a competency for the six main competency areas. These areas broadly parallel those specified by the ACGME as "core competencies" for all specialties, with one exception; the term "clinical science" has replaced the area referred to by the ACGME as "medical knowledge." Section VII.A.5 of the new RRC Program Requirements for Residency Education in Child and Adolescent Psychiatry states: "Programs must develop at least one written core competency for its residents in each of the following areas: a) clinical science, b) interpersonal skills and communication, c) patient care, d) practice-based learning and improvement, e) professionalism and ethical behavior, and f) systems-based care" (14). The RRC also requires documented evidence to demonstrate that the proficiency/competence of each resident is assessed, using techniques that may include supervisory reports, videotapes, oral examinations, case reports, patient care observations, or other methods (14).
The ACGME envisions the definition of competencies as the "first step in a long-term effort designed to emphasize educational outcome assessment in residency programs in the accreditation process" (13). Subsequent steps in this long-term endeavor to improve the quality of medical training will include the development of assessment methods and faculty education activities that incorporate an outcomes-based approach. Ultimately, each specialty will be required to develop criterion-referenced standard-setting procedures for measuring achievement of these competencies (3,5). It is expected that this process will evolve over time, with each specialty working first to achieve consensus about its particular competencies and then to develop assessment measures to evaluate these competencies both during residency training and on graduation. Assessment methods that are both educationally and psychometrically sound will be needed to ensure adequate educational outcome assessment of the defined competencies in each specialty.
The mission at this point, for the field generally and for child and adolescent psychiatry in particular, is not to immediately implement these requirements, but to begin to define potential competencies in the six main areas informed by earlier efforts to define core curriculum for postgraduate training in child and adolescent psychiatry (15,16). Subsequently, specific methods for assessing these competencies must be developed and implemented. It is expected that each training program will identify competencies that are based on its own priorities and strengths, and will test assessment approaches that are best suited for their individual programs. During the next several years, numerous examples from training programs and professional organizational efforts (including the RRC) should direct the field toward a consensus regarding competencies and related assessment methods for child and adolescent psychiatrists.
It is within the context of this national movement that the Work Group on Training and Education (WG) of the American Academy of Child and Adolescent Psychiatry (AACAP) undertook the task of providing sample core competencies for training programs. This paper offers potential templates for competencies that training directors may use as a starting point from which to develop core competencies for their own individual programs. These samples are just that—examples—developed to offer initial potential models to the field, and not to define the competencies themselves. Definition of the specific competencies is a process that the WG believes will evolve from the field over the next few years, and will not emanate from a committee.
This paper does not address the issues of assessment and remediation in a substantive way. These topics are currently under review by the WG and will be the subject of a future publication.
The AACAP Work Group on Training developed these sample competencies in the six main areas over an 18-month period. Five regularly scheduled meetings were convened for this task. Initially, the WG reviewed the existing literature on competencies across medical specialties, as well as the ACGME Outcome Project general competencies. A format for these competencies was then developed that addressed the essential issues of knowledge, skills, and attitudes for each specific competency, followed by a section identifying preliminary potential methodology for its assessment or measurement (t1). After achieving consensus regarding format, the WG assigned each of the six competency areas to a pair of members. The two-member teams were then charged with developing a preliminary draft of an example of a competency for child and adolescent psychiatry for that particular area. They were instructed to keep the competency broadly defined and flexible. Between the meetings, the two-member teams revised drafts via correspondence by e-mail, fax, and telephone. The AACAP Work Group then convened a two-day meeting in July 2000 to review these draft competencies and refine them through discussion and revision. Subsequent drafts were then presented to a group of child and adolescent psychiatry training directors at the Annual Meeting of the AACAP in October 2000 for review and discussion. With this feedback, the draft competencies were revised by the original authors and reviewed by the WG as a whole. When content was finalized, the competencies were edited by two WG members to establish greater consistency in format across the six examples, and they were then distributed for final review.
Examples of child and adolescent psychiatry core competencies for clinical science (t2), patient care (t3,t4,t5), interpersonal skills and communication (t1), practice-based learning and improvement (t7), professionalism and ethical behavior (t8), and systems-based care (t9) are provided. When applicable, definitions from the ACGME Outcome Project are included (13). To demonstrate how competencies should vary even within this general format, the patient care competencies were subdivided into different approaches and categorized by type of treatment modality; namely psychotherapy (t3), psychopharmacology (t4), and crisis intervention (t5).
Directors of child and adolescent psychiatry training programs have long aspired to quality education for physicians dedicated to becoming child and adolescent psychiatrists. The challenge educators face is to produce well-trained physicians who can implement state-of-the-art diagnostic and therapeutic tools, as well as adapt their practices to integrate significant advances in the field over time (16). With the advent of the ACGME Outcome Project, and the resulting changes in the RRC Program Requirements, the need to objectively define and measure a physician's mastery of these skills has become paramount.
In this paper, the WG has developed preliminary examples of competencies for child and adolescent psychiatry to stimulate training directors and to encourage them to develop their own specific competencies and to share these competencies with the field. In the process of developing competencies, it is important to realize that these examples should be of "core" competencies, not comprehensive ones. In most cases, they will incorporate educational goals that training directors already embrace. It is imperative that the competencies should be written such that implementation is possible in a wide variety of programs, large or small, regardless of resources. These templates reflect baseline competencies that are reasonable for a trainee to achieve by the time of graduation from training and may not address the overall competencies expected of an experienced child and adolescent psychiatrist.
These samples, and the ones that training directors across the country will develop over the next several years, are not mandates but a starting point from which we can begin the process of reaching consensus regarding "core" competencies for our field. This is the first stage of the ACGME Outcome Project, whose name implies the ultimate goal—that of emphasizing "educational outcome assessment," whereby training programs will develop and use dependable measures to assess resident accomplishment of the defined core competencies (13). Emphasis upon demonstration of competency by physicians-in-training focuses attention on methods of evaluation and measurement of knowledge, skill, and attitude attainment. With each sample competency, it is imperative that practical assessment methodology ultimately be incorporated to determine outcome and to assure achievement of educational goals.
Although instituting these new requirements may increase anxiety among training directors and trainees in the short run, the implementation process over the next decade will certainly lead to more effective training, assessment, and remediation methods for the field. These samples for "core" competencies in child and adolescent psychiatry are a beginning. The next step is to look more closely at evaluation and remediation methodologies and to prioritize those that have greater potential for being easily implemented across training programs. To begin this work, the WG's project for 2001 is to critically examine existing assessment and remediation methods and, from that review, to propose evaluation methods that could be piloted and to identify some of the complex issues related to remediation.
The authors thank Ms. Florence Sterni for her editorial assistance. This work was supported in part by the American Academy of Child and Adolescent Psychiatry.