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In 1910, Flexner issued to the Carnegie
Foundation a report on the state of medical education1 that
transformed the training of physicians in the United States. Residency
training, modeled on the Flexner report, was an apprenticeship in
hospitals. Residency training evolved to include structured curricula
and specified clinical experiences designed to develop knowledge,
skills, and behaviors of physicians within each specialty and general
discipline. Over time, the context of training programs changed
rapidly as teaching hospitals accomplished their missions of patient
care, research, and education while attempting to stay financially
solvent in an increasingly competitive medical marketplace. The
increasing complexity of patient care and that of the medical care
system imposed additional challenges to the environment in which
residents were trained.
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The evolution of individual training programs and the graduate
medical education enterprise in general did not keep pace with these
changes.2 During this same time period, despite
enormous advances in medical science and achievements in altering
the natural history of disease, the medical profession failed to stay
focused on the quality of care, as reported by the Institute of
Medicine in 2000.3 As a result, public trust in
the medical profession has eroded in the United States. One response within
organized medicine was to examine the training of physicians and
focus on the outcomes of training rather than merely on the structure
and process of training, a shift that represents a huge transformation
in graduate medical education to competency-based training. The
Accreditation Council for Graduate Medical Education (ACGME) incorporated the
following six competencies into the training requirements for all
accredited residency training programs: patient care, medical knowledge,
practice-based learning and improvement, interpersonal and communication
skills, professionalism, and systems-based practice.4 These
competencies have been embraced throughout organized medicine. The
American Board of Medical Specialties (ABMS) adopted the competencies for
maintenance of certification for specialists, and the Joint Commission
for the Accreditation of Healthcare Organizations (JCAHO) suggests
that medical staffs incorporate the assessment of competence into
credentialing practices.5,6 The assessment of competence along
the continuum of professional development is directly linked to
the intended outcome of improving quality of care. Although this chapter
examines the competencies in pediatrics from the perspective of
residency training, measurement of achievement of these same competencies
for certification will eventually be applied throughout the profession
of pediatrics.
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Epstein and Hundert define professional competence as “the
habitual and judicious use of communication, knowledge, technical
skills, clinical reasoning, emotions, values and reflection in daily
practice for the benefit of the individual and community being served.”7 The
attainment of competence occurs gradually over time in a developmental
progression. Dreyfus and Dreyfus observed this progression in other
realms, but their model may be applied to the development of professional competence
in medicine, from medical school through residency and into later
professional life.8 The stages they describe are
novice, advanced beginner, competent, proficient, expert, and master.
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A simplified description of ...