Pick six

Six core competencies in medical education have stood the test of time. Six more could help physicians understand what it means to be a competent internist.


If the six Accreditation Council for Graduate Medical Education (ACGME) Core Competencies did not already exist, which would you choose in their place? I'll go first. I'll restrict myself to six, because if the list approached 10, coming from the President of ACP, of course, they might be misconstrued as commandments, and that's the last outcome I would want. You see, I am not that certain about my six choices. I hope you will chime in.

The six competencies we are working with now were put forward by the ACGME in 1999 (think introduction of the Euro, think Y2K) to provide a framework for evaluation in graduate medical education. Nothing so informs curriculum as evaluation, so it's not surprising that the six competencies soon came to also represent the framework for residency curriculum. And there's more. They also provide a framework for the Internal Medicine Milestones used to assess each resident's development. They even have been adapted for use by credentialing committees to determine whether physicians should be credentialed.

What are these competencies? They are Practice-Based Learning, Patient Care and Procedural Skills, Systems-Based Practice, Medical Knowledge, Interpersonal and Communication Skills, and Professionalism. I have no problem with any of them, and clearly they have stood the test of time. But that is not to say they should be frozen in time.

Steven E. Weinberger, MD, MACP, ACP's EVP/CEO Emeritus, broke the ice in 2011 with his paper in Annals of Internal Medicine titled “Providing High-Value, Cost Conscious Care: A Critical Seventh General Competency for Physicians.” His approach was to retain the original six competencies and suggest a seventh. While my year as President gives me pause in suggesting a strategy of “repeal and replace,” in this case, I believe, it may be helpful to make a fresh start.

I'll start where Dr. Weinberger left off, with my first essential competency—high-value care, because it is so critical. It is our version of the “tragedy of the commons” in which resources are finite and overuse by any individual eventually harms others. Eliminating waste, improving cost-effective diagnostic skills, avoiding inappropriate and expensive tests and therapies when less expensive choices are available, and appreciating that, in some situations, less can be more are all components of my first new competency.

My second is knowing how and when to reframe; that's “reframe,” not “refrain.” Reframing refers to taking a step back and looking at a problem differently, so that unappreciated aspects come more clearly into view. Reframing is not that difficult; it's knowing when to do it that is hard. In the parlance of clinical reasoning, we tend to handle clinical problems through fast thinking or pattern recognition. At least that's where we begin. The truly competent clinician, however, knows when it's time to pivot to a more analytic form of problem solving, when the patient is not doing well or the diagnosis is not apparent. Medical knowledge, or at least having the correct information in front of you, is assumed here. Reframing implies putting that knowledge to proper use and thinking about the case in a different way. Think about all the times you've seen a master clinician come up with an alternative formulation, and you'll appreciate how important reframing can be.

Emotional intelligence is my third competency. Not easily defined, emotional intelligence includes self-awareness, self-regulation, motivation, empathy, and social skills. It is what enables you to understand and help others and also understand and help yourself. Physicians with high emotional intelligence are skilled at learning from their experiences and never taking themselves too seriously.

A story is told about the famous hematologist and eminent teacher, the late Richard Vilter, MD, MACP. One of Dr. Vilter's former residents mustered his courage one day and asked, “You are such a marvelous clinician. To what do you attribute your success?” Dr. Vilter replied, “Good judgment.” The questioner thought for a moment and, not completely satisfied with the response, asked, “But Dr. Vilter, to what do you attribute your good judgment?” Dr. Vilter said, “Experience.” Still not satisfied, the questioner pursued it one step further. “But Dr. Vilter, how does one gain experience?” Dr. Vilter responded, “Bad judgment.”

Curiosity is the next competency I would like us to consider. This may be a surprising addition to my list of six, but think for a moment. What characterizes the best residents, the best clinicians? Is it not their level of curiosity, their interest in learning more, their desire to get to the bottom of what is happening? The word derives from the Latin cura, or care, and is defined in Wikipedia as “…a quality related to inquisitive thinking such as exploration, investigation, and learning.” “Curiosity,” the Wikipedia entry continues, “is heavily associated with the process of learning and the drive to acquire knowledge and skills.” We certainly can ask, can curiosity be acquired? Is it a competency that can be demonstrated? I believe such traits can and are, but I'll explain more about that when we examine the one holdover from the official list, which is Professionalism.

But first, allow me to provide my replacement for the fifth competency, Interpersonal and Communication Skills, and that is Kindness. I am not implying here that explicit communication skills such as addressing emotion or delivering bad news do not exist and need not be practiced and learned. Of course they do. But learning and practice mean little if those skills are not put to use.

In his book “The Tipping Point,” Malcolm Gladwell recounts an experiment in which some seminarians studied the story of the Good Samaritan, and others did not. Then, unbeknownst to both groups, the seminarians were observed in a situation where they encountered an injured person while they were walking across campus.

It turned out whether the seminarians stopped to provide aid had little to do with their knowledge of the story of the Good Samaritan. It seemed to depend more on how rushed they were. I suspect it also depended on how kind they were. Kindness has you go back and see a patient after rounds because you are worried that he is worried, or take an extra moment in the office because a patient needs more time.

This brings me to my last competency, Professionalism, which I include on my list as the ACGME did on theirs. Not easily defined because it embraces so many characteristics, from primacy of patient welfare to respect for autonomy, social justice, collegiality, and managing conflict of interest, Professionalism challenges educators and scholars alike. My favorite definition of Professionalism comes from our own Tom Huddle, MD, PhD, FACP, who, interestingly, objects to Professionalism being considered a competency like reading an ECG is a competency. All the same, the definition of Professionalism Dr. Huddle provides will serve us well. Professionalism, he wrote in 2005 in Academic Medicine, is doing the right thing when no one is watching. Of course it's difficult to assess a competency if it is not observed, but the point is, in a system such as an office practice, or an inpatient unit, or a nursing home, one knows what's happening even when one is not there. Moreover, there are wonderful moments of professionalism you can observe from the corner of your eye. Competency or not, Professionalism makes my list.

So there is my updated list of competencies: practicing High-Value Care, knowing when to Reframe, having Emotional Intelligence, demonstrating Curiosity, acting with Kindness, and behaving with Professionalism. I am not sure my list is ready to shape a curriculum or provide a framework for the next version of Milestones. But I do have a sense it will help me understand what it means to be a competent internist.

It is an honor serving as your President and sharing my thoughts with you. Please let me hear from you.