Susan D. Wolfsthal

Shifting Paradigms: From Flexner to Competencies.

Realizing medical education is on the brink of a major paradigm shift from structure- and process-based to competency-based education and measurement of outcomes, the authors reviewed the existing medical literature to provide practical insight into how to accomplish full implementation and evaluation of this new paradigm. They searched Medline and the Educational Resource Information Clearinghouse from the 1960s until the present, reviewed the titles and abstracts of the 469 articles the search produced, and chose 68 relevant articles for full review. The authors found that in the 1970s and 1980s much attention was given to the need for and the development of professional competencies for many medical disciplines. Little attention, however, was devoted to defining the benchmarks of specific competencies, how to attain them, or the evaluation of competence. Lack of evaluation strategies was likely one of the forces responsible for the three-decade lag between initiation of the movement and wide-spread adoption. Lessons learned from past experiences include the importance of strategic planning and faculty and learner buy-in for defining competencies. In addition, the benchmarks for defining competency and the thresholds for attaining competence must be clearly delineated. The development of appropriate assessment tools to measure competence remains the challenge of this decade, and educators must be responsible for studying the impact of this paradigm shift to determine whether its ultimate effect is the production of more competent physicians.

Is blood pressure control necessary before surgery

The need for blood pressure control before elective surgery depends on the degree and type of hypertension and the presence of other cardiovascular risk factors. Although blood pressure should be normalized in most patients for several months before surgery, mild to moderate diastolic or systolic hypertension do not place the patient at increased operative risk. Mild to moderate elevations should not be acutely controlled in the few days before surgery. Higher blood pressure elevations confer an increased operative risk and must be carefully controlled before surgery. Blood pressure control with certain antihypertensive medications confers a protective effect on the risk of intraoperative instability. The impact of preoperative control of hypertension in relationship to these variables is incorporated into useful recommendations for clinical practice.

Web-based training improves knowledge about central line bloodstream infections.

A Web-based training course with embedded video clips for reducing central line-associated bloodstream infections (CLABSIs) was evaluated and shown to improve clinician knowledge and retention of knowledge over time. To our knowledge, this is the first study to evaluate Web-based CLABSI training as a stand-alone intervention.

Creative solution for implementation of experiential, competency-based palliative care training for internal medicine residents.

To graduate internal medicine residents with basic competency in palliative care, we employ a two-pronged strategy targeted at both residents and attending physicians as learners. The first prong provides a knowledge foundation using web-based learning programs designed specifically for residents and clinical faculty members. The second prong is assessment of resident competency in key palliative care domains by faculty members using direct observation during clinical rotations. The faculty training program contains Competency Assessment Tools addressing 19 topics distributed amongst four broad palliative care domains designed to assist faculty members in making the clinical competency assessments. Residents are required to complete their web-based training by the end of their internship year; they must demonstrate competency in one skill from each of the four broad palliative care domains prior to graduation. Resident and faculty evaluation of the training programs is favorable. Outcome-based measures are planned to evaluate long-term program effectiveness.