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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.

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.

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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