Five months after the conference, THCI wrote to all attendees. Here are the questions asked and excerpts from the responses.

A. We'd like to know what specific steps you have taken to improve your institution's or program's training and assessment of new physicians, since the THCI national conference last September in Boston.

1. Define goals and objectives for training in the new competencies.
• I am designing concrete goals and objectives for each rotation in our residency, which, when completed, will document competence in a number of core skills, knowledge areas, and procedures.
• I have been working closely with another member of our education division, a Ph.D. educator, to develop objectives for each rotation that specifically address the competencies. I then meet with each division director to hone these objectives.
• We are serially updating each curriculum statement with objectives that can be classified by ACGME criteria, which can be compiled and analyzed in data base fashion.
• We are rewriting curriculum statements to reflect what we were already doing well, but weren't documenting according to the new criteria.
  
  
2. Design and implement new instructional activities.
• Our patient safety lecture series incorporates nursing, administration, legal, doctors, ancillary staff and patients.
• We are in the process of designing a chart review for continuity clinic to model practice-based learning and improvement.
• We are adding some evidence-based medicine activities to our morbidity and mortality conference format.
• I am developing an evidence-based medicine project with a group of Ob/Gyn residents.
  
  
3. Develop new assessment instruments, or improve existing ones.
• We now include competency language in all assessment & evaluation tools.
• We developed "Comment Cards" for point of care feedback to residents during patient care sessions, evaluating one of the 6 competencies, but particularly practice-based learning and systems-based practice.
• I am creating some checklists to document the performance of specific activities that will comprise the goals and objectives for our rotations.
• I have convened a group of residents and nurses who will work on portions of a 360-degree evaluation.
• We are now "on line" for all housestaff evaluations, and will be employing a simpler rating scale.
• The University has helped in purchasing a central database collection system that will allow us to document and assess the residents.
• The change to electronic evaluations will hopefully expedite data gathering, and improve the process.
  
  
4. Engage institutional leaders and/or faculty in changes around the competencies.
• I presented summaries of the conference at several faculty meetings.
• We held faculty development sessions on the competencies.
• We held a residency retreat on giving effective feedback.
• I have presented the competencies and "toolbox" to division directors; we are soliciting their input in identifying which competencies are being assessed with which tools in their rotations.
• I am working with our associate dean for GME to have multiple departments collaborate on teaching things that all of our residents need, such as ethics and professionalism.
• We now include "Mini-faculty development" on competency assessment and evaluation at each monthly faculty meeting.
• Local faculty are being individually groomed for "competency in competencies."
• I have given 3 lectures to the staff and residents regarding the 6 competencies and the 5 new instruments we are using to assess the residents.
• Attending staff will be briefed regarding the new competencies at the start of each month of ward service.
  
  
5. Familiarize residents with the competencies and requirements.
• I have had several communications with residents regarding the competencies.
• I developed a website about the competencies.
• The competencies are discussed at meetings, lectures, evaluations, and daily review of patient work.
• We had all faculty and residents memorize the 6 competencies (gave them the assignment and then gave a written quiz they were given at our residency retreat).
• We posted the competencies prominently in our patient care "preceptor" room in our family health center.
• Large posters with the competencies have been put up in several area of the residency.

B. What are the most significant barriers to accomplishing your goals?

• Lack of time for more curriculum development.
• Time - my time, faculty time, resident time.
• Lack of resources.
• Lack of funding for provision of additional resources.
• The lack of an electronic medical record to enhance our ability to provide residents data on their practice activities.
• Acquiring computer equipment and support.
• General institutional inertia.
• Complex organization of academic medical center - multiple entities without facile collaboration.
• Achieving a consistency in goals among a variety of residency programs.
• Lack of previous training in education and assessment methodology among all faculty.
• Many of our faculty do not take the competencies seriously - they believe the whole project may disappear. Other faculty believe that superficial changes to their existing programs will suffice.
• Faculty resistance to documentation due to lack of time in an already busy day.
• Physicians caring about or finding value in the competency requirements. Getting voluntary community physicians who serve as attendings to incorporate competency perspective.
• Faculty development.
• Inertia on the part of the house staff. They feel they don't have the time to do additional work required by the program.
• It's difficult for residents to place these requirements high up on the priority list. Faculty support is critical and has been difficult.
• Our challenge now is not overwhelming our residents or faculty. The residents are aware of the competency requirements but don't seem to focus their attention, practice, or thinking around them very much. The competencies are still a formality without a whole lot of substance. This is changing, but slowly. The challenge is the mindset and the workload, not the competencies or the assessment themselves. This is an apprenticeship/modeling profession, and, in a way, we're trying to implement the competencies bottom-up, which almost never works in a traditional business organization. This emphasizes the importance of faculty development and this may be the area with the most resistance and the least amount of attention/interest.