School's back: The dilemma of practice-based learning

With the return to school in the fall comes both the relief that parents feel that the summer is over and the complaints they begin to hear regarding new teachers and assignments. My 16-year-old daughter recently was complaining about an assignment that seemed particularly difficult because her teacher did not clearly communicate to the students what he actually wanted them to accomplish. Of course, she was not asking for parental advice. She had already contacted her fellow classmates regarding their impressions, most likely through texting, to express her dismay (OMG!!!) and solicit advice.

We also have our own difficult assignments. As I talk with medical staffs about the challenges they have faced in implementing OPPE using The Joint Commission/ Accreditation Council for Graduate Medical Education (ACGME) six general competencies framework, the one category that seems to cause the most consternation is practiced-based learning. There seems to be two issues causing their concern:

1. What does it mean?
2. How do you measure it?

Just like my daughter, medical staffs, too, have asked their colleagues only to find that they also are struggling with this assignment. And, just like my daughter's complaint, it seems that the root cause is that the teacher, in this case, The Joint Commission, did not explain the assignment very well or, perhaps, did not fully think it through.

In this column, I would like to address the first question in this month’s column and the second question next month.

To understand the situation, one must take a step back to understand why the physician competency framework was first developed. ACGME and ABMS designed it for evaluating residents and board diplomates, respectively, not for evaluating attending physicians and hospital medical staff setting. Although I believe the framework very useful for most of the competencies, practice-based learning faces a particular challenge. In both of the original settings for this competency, there is the capacity to test learning. But in a hospital medical staff setting, systems are not in place for physicians to demonstrate learning based on prior practice and data. Although continuing medical education (CME) credits show that knowledge has been obtained, CME does not demonstrate whether this is been applied to their daily practice.

First, what does practice-based learning mean? The Joint Commission and the ACGME explain in the following statements:

Joint Commission: Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care.

ACGME: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.

The ACGME went on to further elaborate on this statement by defining six specific behavioral expectations that would help evaluate practice-based learning:

1. Analyze practice experience and perform practice-based improvement activities using a systematic methodology
2. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
3. Obtain and use information about their own population of patients and the larger population from which their patients are drawn
4. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
5. Use information technology to manage information, access online medical information, and support their own education
6. Facilitate the learning of students and other healthcare professionals.

Unfortunately, The Joint Commission did not elaborate for this or any other competency category just what it expected. Herein lays the dilemma, and the debate, of what does this competency mean for hospital medical staffs. In working with hospital medical staffs over the past three years, The Greeley Company has been able to define four expectations for this competency that resonate with attending physicians:

1. Regularly review your individual and specialty data for all general competencies and use the data for self improvement of patient care
2. When contacted about patient care concerns, respond in a constructive manner
3. Use hospital information technology to manage information and access online medical information
4. Facilitate the learning of students, trainees, and other healthcare professionals.

Based on these expectations, we can at least begin to think through if and how practice-based learning can be measured and evaluated to improve the physician performance and, ultimately, patient care. Next month, we will discuss ideas on how this can be accomplished.

Robert J. Marder, MD, CMSL, is the vice president of The Greeley Company, a division of HCPro, Inc.