Before 2001, there were no uniform standards of evaluating resident-trainees - programs depended mainly upon ad hoc local standards and assessment tools. This lack of uniform inter- and intra-program standards of evaluation led the American Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties to suggest fundamental changes of the methods used to evaluate residents. In Summer 2001, the ACGME mandated that resident-trainees be evaluated in 6 core competencies:

1. Medical Knowledge
2. Patient Care
3. Professionalism
4. Communication Skills
5. Practice-Based Learning
6. Systems-Based Learning

More information describing these competencies and the ACGME is available at: http://www.acgme.org/Outcome. Bridgeport Hospital has embraced this initiative. We believe that medical educators have heretofore done a good job evaluating medical knowledge, but the equally important competencies #2-6 were not well assessed and thus valuable doctoring skills have been left undeveloped. We participated in what promises to be a landmark study, conducted by Yale and the Uniformed Services University, of medical evaluation. We were lucky to be randomized to the intervention arm of this study and thereby benefited from a comprehensive program to improve evaluation of the competencies. Consequently, we have implemented many innovative techniques that are delineated in this section of the website. Luckily we are a small enough program where implementation of such intensive evaluation is possible. Indeed it may seem daunting to be evaluated so comprehensively and frequently. However, we view evaluations as purely constructive exercises - we agree with the ACGME that these efforts will make our trainees better doctors. (Click on one of the competencies listed above to learn more.)

We have outlined, in some detail, many of the techniques we use to teach and evaluate the 6 ACGME competencies. This is a "work-in-progress" which we are constantly updating and refining.


CA Manthous, MD, FACP, FCCP
Director of Internal Medicine Residency and
Medical Intensive Care
Bridgeport Hospital
Associate Clinical Professor of Medicine
Yale University School of Medicine

1. 360° Evaluations

This refers to the process whereby our residents are evaluated by all parties with whom they interact in the health care system i.e. patients, nurses, discharge planners, attending physicians, peers and themselves. Each respondent receives a short questionnaire asking for their assessment in areas that are germane to their interactions with the residents. For example, we don't ask nurses to evaluate fund of medical knowledge. We do ask them to rate whether our residents treat them with appropriate respect, whether they have seen the residents treat their patients with respect and whether they would want our residents to care for their loved ones. Accordingly, each resident is given feedback that helps define strengths and weaknesses of their performance. Areas of professionalism and interpersonal skills, that have heretofore remained poorly addressed, are now examined from multiple angles. The 360° approach has the potential, when all viewpoints are combined, to assess all 6 medical competencies - each observer offering a different puzzle piece of the ACGME evaluation construct.

2. Observed Exercises

Full Clinical Evaluation Exercise (CEX) - Each year our residents perform a full history and physical examination that is observed by a faculty member. Their performance is rated using ABIM tools, and they are given feedback on areas in which they can improve. These exercises assess "interpersonal skills and medical knowledge" competencies.

Mini-CEX - Refers to simply evaluating a single component of performance, like history-taking or physical examination skills. We have implemented mini-CEXs to evaluate the following areas: in- and outpatient physical examination skills, outpatient counseling sessions and history-taking. These exercises assess "interpersonal skills and medical knowledge" competencies.

Case presentations - Residents are periodically graded on their ability to present cases in detail in Teaching Attending rounds. They are also formally evaluated in periodic morning reports and during Work Rounds on what we call a "10-minute presentation" - a brief summary of a patient's history/physical/studies/hospital course which includes items that a consultant would want to know without the "extras" needed in the full presentation. These exercises address the "communication skills" competency.

Medical Reasoning and History-taking Exercise - In Morning Report, a resident is chosen to take a 5-minute history from an attending, who pretends to be a patient presenting with an acute illness. Residents and attending physicians then discuss the resident's performance, offering constructive criticism for interpersonal skills, problem-solving and synthetic medical reasoning. Both the resident performing the exercise and those who observe benefit from a frank discussion of how to improve their clinical effectiveness. This exercise speaks to "medical knowledge, interpersonal/communication skills, and professionalism."

3. Objective Structured Clinical Examination (OSCE)

We have designed a custom, in-house OSCE to assess each of the 6 Medical Competencies. Starting in Spring 2003 and then yearly thereafter, our residents will perform a one-hour OSCE consisting of 6 stations. Residents will receive feedback from "trained patients" and written answers with annotated bibliographies.

4. Medical Records Review

Self-assessment
Each year, residents will be given homework: to assess their outpatient panel of patients for the degree to which they have received state-of-the art care. Residents will examine 10 medical records, using evidence-based criteria of ideal care, and they will grade themselves on their performance in that arena. They will be asked to do the exact same exercise 6 months later to determine whether they've modified (hopefully for the better) their patient care skills. This exercise speaks to "practice-based learning."

Hospital quality improvement project
Each year, after collaborating with hospital quality assurance personnel, the PGY-1 or 2 class will have the opportunity to take up a patient quality of care research project. For example, the proposed project for 2003 is to create an intervention to increase the frequency of prophylaxis for deep venous thrombosis in at-risk hospitalized patients. The class will devise a research protocol for obtaining and analyzing pre- and post-intervention data. This exercise speaks to both "practice- and system-based learning" competencies. It also introduces residents to basic concepts in study design and scientific approach.

Improvement of medical documentation
Just as it sounds this is a regular review of medical records and discharge summaries using a standardized measurement tool to assure that the elements of proper medical documentation are included in trainees' notes.

Chart-stimulated recall
During chart-checks for documentation, the director also reviews with trainees' their understanding of patient problems - both active problems and those (like nutrition and psychosocial aspects that are not readily apparent, but also important).

5. Objective Assessment of Medical Knowledge

All residents sit for the American Board of Internal Medicine in-service examination each year. Results are discussed in conferences with the program director to identify areas of strength and weakness. Although these tests are not used uniquely to define competency of medical knowledge, they are a potent predictor of performance on the Board Certifying Examination. Accordingly, those with marginal scores receive counseling on how to approach self-study and some receive guided study sessions. This test speaks to the "medical knowledge" competency.