Models for enhancingcompetency-basedtraining and contextualclinical decision makingImad Hassan, Department of Medicine, King Abdulaziz Medical City, King Fahad NationalGuard Hospital, Riyadh, Kingdom of Saudi Arabia

SUMMARYBackground: In the era of qualitycare, competency and outcome-based education, new models ofteaching and resident staff train-ing are greatly needed. Theseshould be based on adult learningprinciples and allow for high-quality, patient-centred, evi-dence-based care.Context: Three areas that needrestructuring with specific con-ceptual frameworks to allow forseamless competency-basedtraining, and also to assist inputting the decision-makingprocess in context, are: case ortopic presentation; diagnosticlabelling; and immediate

interventions for front-line care-givers.Innovation: Three models areproposed: the competency-structured presentation (CSP)model; the bedside clinicaldiagnosis, etiological cause andseverity score diagnostic labelling(BESD) model; and the symptom-atic, supportive, specific, spe-cialty and site of care (5S) model.Implications: The models listedabove may assist in the followingdomains of patient care. In acompetency-structured presenta-tion, the CSP model formalisescase presentations and discus-sions in a competency-basedstructure, thereby supporting the

development of a competency-focused thought process forpatient care. The BESD and 5Smodels improve the understand-ing of patient problems within theappropriate context, and thusassists in achieving the followingquality outcomes. The BESD modelpromotes better diagnostic label-ling, thereby assisting in imple-menting individualised, evidence-based interventions. The 5S modelpromotes the cognitive concep-tualisation of medical manage-ment, which will aid a morecomprehensive, patient-centred,multidisciplinary care input,thereby reducing process errorsand improving outcomes.

New models ofteaching and

resident stafftraining are

needed

Frameworks

for education

392 � Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397

INTRODUCTION

Quality of care and compe-tency-based training aretwo intimately linked

concepts.1

Quality of careThe Institute of Medicine hasdefined quality of care as ‘thedegree to which health servicesfor individuals and populationsincrease the likelihood ofdesired health outcomes and areconsistent with current profes-sional knowledge’.2 Six outcomesare emphasised: patient safety;patient centredness; effective-ness; efficiency; timeliness; andequity. These are geared towardsthe prevention or reduction ofthe six ‘D’s of patient careoutcome: death; disease; dis-ability; discomfort; dissatisfac-tion; and destitution (cost ofcare). Evidently, health caresystems, and especially the staff,must be specifically empoweredwith all the knowledge and skillsnecessary to attain theseoutcomes.

Competency-based trainingUnfortunately, old-style residenttraining is unlikely to equip thetrainees with all the necessaryskills for such a comprehensivelook at patient care. New ‘resi-dent competencies’ beyond sim-ple clinical skill building areclearly necessary. Unavoidably,new structures and processes forresident staff training, particu-larly in the active clinical deci-sion process, need to be put inplace to achieve these outcomes.The move by medical trainingbodies in America, Europe andelsewhere to restructure theiraccreditation programmes is adirect consequence of this.3–5 Inall of these programmes, out-come-based, competency-direc-ted training frameworks wereemphasised. The CanMeds frame-work (Table S1) is an excellentexample of such a programme.3,4

It explicitly states that for apractising physician to be fully

competent, he or she must beproficient in seven domains ofknowledge and skill. These so-called meta-competencies includecompetencies as a medical ex-pert, communicator, collaborator,scholar, advocate, manager andprofessional. However, details ofgeneric concepts to allow for aseamless incorporation of thesecompetencies into everydaypractice are not always explicitlyoutlined.

Novel, friendly strategies totrain and empower front-linestaff, reduce inefficiencies in thecare process and improve patientoutcomes are needed. The threeproposed models below may helpin realising some of the afore-mentioned competencies by mak-ing them part of the routine inresident education, and in deci-sion making when formulating amanagement plan for a specificpatient. They may thus equipresidents with strategies to man-age patient complexities anduncertainties, reduce processerrors and ultimately achieve thedesired quality outcomes.

The proposed models are pri-marily based on the author’s longexperience in medical staff train-ing in clinical care and in mech-anisms to enhance theimplementation of evidence-based medicine.

A COMPETENCY-STRUCTUREDPRESENTATION (CSP)MODEL, USING THECANMEDS FRAMEWORK

Classically, and for educationalpurposes, both undergraduatesand postgraduates present clinicaltopics in a narrative or case-basedstyle. In both of these, classicheadings that are used includedefinitions, etiology, epidemiol-ogy, clinical presentation, differ-ential diagnosis, investigations,therapy and prognosis etc. Thisform of presentation does not

explicitly emphasise the newdomains of knowledge or skillsnecessary for quality of care, asoutlined above, or empower thetrainees with all the competenciesoutlined by CanMeds, or similarbodies, for comprehensive, out-come-based training and patientcare. A proposed scheme for topicpresentation is outlined below.Topic headings are now deliber-ately portrayed under competencyheadings. Presumably, this con-ceptual framework or map wouldassist in realising a more compe-tency-directed clinical trainingand decision-making process, andin drafting a comprehensive,high-quality management plan forevery patient. Practical, patient-centred care actions and inter-ventions may thus be incorpo-rated in the clinical decisionprocess. Table S2, available on-line, depicts the presentationoutlines for two common medicaltopics, namely stroke and bron-chial asthma. It compiles all thenecessary knowledge and skillsunder the CanMeds competency-based educational framework.Once completed, the exercisewould have emphasised to thetrainees and residents all of theconcepts that are conducive forcomprehensive, multidisciplinary,quality care. It is vital to high-light here that active training inrelevant practical skills is anessential component of the exer-cise: e.g. training residents in

New ‘residentcompetencies’beyond simpleclinical skillbuilding areclearlynecessary

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inhaler technique or in peak flowmeter recording, in the exampleof bronchial asthma, which areskills not normally included inold-style lectures.

CONCEPTUAL FRAMEWORKFOR COMPREHENSIVEGUIDELINE-FRIENDLYDIAGNOSTIC LABELLING:THE BEDSIDE CLINICALDIAGNOSIS, ETIOLOGY,SEVERITY DIAGNOSTIC(BESD) MODEL

So often, when residents areasked for their clinical diagnosis,an incomplete and clearly seri-ously deficient label is given. Inmy opinion this hinders proper,comprehensive, guideline-based,therapeutic interventions, withan unmistakable negative impact

on the quality of care. Forexample, labelling a patient withan exacerbation of bronchialasthma or heart failure, as such,without explicitly including theprobable precipitant and degreeof severity (and therefore thenecessity for admission to hos-pital or an intensive care ward)will hinder appropriate guide-line-directed immediate care,and also any additional inter-ventions needed to reduce theduration of stay, the cost of careand the future use of the healthcare system. With this in mind,residents must be trained onunequivocally including the fol-lowing three essential elementsin any diagnostic label given toany one patient: the bedsideclinical diagnosis; the etiologicalor precipitating cause; and theseverity score or grade. Table 1

gives two examples. In additionto the clinical diagnosis, a fail-ure to consider the precipitantor cause will inevitably result indeficient care and a poorer out-come. Moreover, the appropriateevidence-based interventions foroptimising the outcome will bedifferent for acute coronarysyndrome or diabetic ketoacido-sis,6,7 with regard to the sites ofcare and recommended interven-tions, e.g. admission to theCoronary Care Unit and a strat-egy of immediate interventionalrevascularisation, for the patientwith the acute coronary syn-drome.

A CONCEPTUALFRAMEWORK FOR PATIENT-CENTRED, COMPREHENSIVE,IMMEDIATE THERAPEUTICINTERVENTIONS: THE 5SMODEL

Similar to the discussion abovefor diagnostic labelling, whenasked about treatment, residentshave a tendency to jump tospecific therapeutic interven-tions, without paying muchattention to important, patient-centred inputs. Such interven-tions may at times be asimportant as the disease-specifictherapeutic interventions them-selves. Apart from the latter,there are at least four othertherapeutically indispensableinterventions that the decision-making process must incorporateas part and parcel of the man-agement plan. These include:symptomatic care; supportivecare; specialty ⁄ subspecialtyinvolvement; and decisions onthe most appropriate site ofcare. Symptomatic treatment isimportant, as it directly allevi-ates patient discomfort. Regret-tably, action to relieve symptomsis not commonly initiated bymedical staff. An excellentexample is the use of analgesicsin the acute-care setting: so-called oligoanalgesia.8 Support-ive care to reverse physiologicalcomplications before damage

Table 1. The bedside clinical diagnosis, etiologicalcause and severity score diagnostic labelling (BESD)model: comprehensive, guideline-friendly diagnosticlabelling

Case scenario 1

A 64-year-old hypertensive and diabetic patient presenting withbreathlessness. Clinically in pulmonary oedema, with gallop and crackles upto his upper chest posterioly and blood pressure of 80 ⁄ 60 mmHg.Electrocardiogram and cardiac enzymes confimed an acute ST -elevationmyocardial infarction.

Bedside clinical diagnosis Etiological diagnosis orprecipitant

Severity

Acute left heart failureand pulmonary oedema

Acute myocardialinfarction

Killip class 4*

Case scenario 2

A 24-year-old patient with type-I diabetes presented with abdominal pain,nausea, vomiting and fever. He has stopped taking his insulin. Urineconfirmed the presence of ketonuria and uncountable pus cells. Plasmaglucose, 630 mg ⁄ dl; ABG revealed a pH of 7.3; bicarbonate 18; aniongap 11.

Bedside clinical diagnosis Etiological diagnosis orprecipitant

Severity

Diabetic ketoacidosis Urinary tract infectionInsulin therapynon-compliance

Mild DKA**

*Killip class 1, no crepitations; class 2, less than 50 per cent creps; class 3,more than 50 per cent crepitations; class 4, cardiogenic shock.

**According to the severity scoring of the American Diabetes Association.

ABG = artierial blood gases, DKA = diabetic ketoacidosis

Failure toconsider the

precipitant orcause willinevitably

result indeficient care

394 � Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397

becomes irreversible, and untilthe precipitant is brought undercontrol by its specific interven-tion, may be life saving. Guide-lines unambiguously dictate thesites of care for specific diseaseseverity scores, e.g. patientswith community-acquired pneu-monia with a CURB-65 (Confu-sion, Urea, Respiratory rate,Blood pressure-65 age in years)score of three or more must bemanaged in intensive care, asopposed to the general ward.9

Similarly, specific high-severityindices for patients with acuteasthma exacerbation entail theneed for higher levels of care.10

Likewise, guidelines recommendearly specialty or subspecialtyreferral for specific acute ill-nesses, e.g. gastroenterology andendoscopy referral for patientswith haematemesis and specificseverity scores, etc. Cognitiveconceptual deficiencies in thedecision making of junior staffhave been shown to be animportant cause for poor out-come in the acute care setting.11

Training residents on routinely,conceptually constructing or

outlining their management planalong the 5S framework may thusassist them in recognising sev-eral of the goals of quality care.Two examples depicting theutility of the 5S framework forfront-line caregivers in the acutesetting are presented in Table 2.It is gratifyingly evident thatthe BESD and 5S conceptualmodels incorporate all sevendomains of the CanMeds compe-tency skills. In my opinion, thesuccessful application of thesemodels hinges on a resident whois highly skilled in most, if notall, of the aforementioned com-petencies. For example, skillfuldiagnostic reasoning and sever-ity assessment requires a com-petent ‘medical expert’,subspecialty referral envisagescollaborative care, with thecommunicator, advocate andprofessional roles being indis-pensable for comprehensive,patient-centred care.

Figure 1 depicts the inter-relationship of the BESD, 5S andCSP models, especially in theacute care setting.

TESTING THE BESD AND 5SMODELS

In an exercise to test the useful-ness of the above models, 21 year-1 residents and interns wererandomly presented with one oftwo case scenarios. One was of a64-year-old patient with acutemyocardial infarction (as pre-sented in Table 1) and the other ofa 70-year-old man with commu-nity-acquired pneumonia (as pre-sented in Table 2). Trainees wererequested to outline their likelydiagnosis and their immediatetherapeutic interventions on ananswer sheet. Once completed,the same case scenario was re-submitted to the trainee, but thistime the answer sheet wasrestructured to conform with theabove two models. The two answersheets were then compared withregards to the explicit inclusion ofthe various domains of case diag-nosis and management, as out-lined in the two models. Apartfrom the symptomatic, supportiveand specific therapeutic inputs,which were relatively comparable

Table 2. Two examples depicting the utility of the symptomatic, supportive,specific, specialty and site of care (5S) model for guiding therapy for front-linecaregivers in the acute setting

Case scenario 1

A 70-year-old, smoker presenting with fever, pleuritic chest pain and breathlessness. Clinically, confused, temperature39.6�C, systolic blood pressure 80 mmHg, respiratory rate 32 ⁄ minute and PaO2 on room air of 54 mmHg. Radiologyconfirmed a diagnosis of multilobar community-acquired pneumonia.

Symptomaticcare

Supportive care Specific care Specialty ⁄subspecialty care

Site of care

AnalgesicsAntipyretic

Oxygen therapyIntravenous fluidsInotropes

Intravenous antibiotics thatchosen are based on severity ⁄site of care: e.g. ceftriaxoneand moxifloxacin, withadditional antipseudomonalcover

Intensive care teamreferral

Intensive care unit,as the CURB-65score is 4.

Case scenario 2

A 17-year-old single, female with a painful sickle cell crisis. Clinically, drowsy, dehydrated and in pain. Haemoglobin45 g ⁄ l. Chest X-ray revealed bilateral infiltrates.

Symptomatic care Supportive care Specific care Specialty ⁄ subspecialtycare

Site of care

Analgesics OxygenHydrationSimple transfusion

AntibioticsExchange transfusion

HaematologistIntensive care Painservice

Intensive care

Guidelinesunambiguouslydictate the sitesof care forspecific diseaseseverity scores

� Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 395

before and after, albeit improved(85.7 versus 95.2%), all otherdomains significantly improved(Figure 2). This confirms that

deficiencies in diagnostic label-ling and in management decisionsare not necessarily the result of alack of knowledge, but are likely to

be a manifestation of a lack of aninternalised cognitive conceptualframework for patient care.

CONCLUSION

This article proposes three simpleinter-related models, the aim ofwhich is to empower residentswith applicable conceptualframeworks for quality care. Caseor clinical topic discussionsshould be designed around acompetency-structured presenta-tion (the CSP model), diagnosticlabelling needs to be comprehen-sive to support the application ofevidence-based guideline recom-mendations (the BESD model) andinitial, acute care decision pro-cesses should encompass all fivedomains of essential, patient-centred, therapeutic interven-tions (the 5S model).

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SUPPORTINGINFORMATION

Additional supporting informa-tion may be found in the online

version of this article at http: ⁄ ⁄onlinelibrary.wiley.com ⁄ doi ⁄10.1111/j.1743-498X.2012.00584.x ⁄ suppinfo

Table S1. The CanMedscompetencies.3

Table S2. The competency-structured presentation (CSP)model: topic presentations;applying the CanMeds roles.

Please note: Wiley-Blackwellare not responsible for thecontent or functionality of anysupporting materials supplied bythe author. Any queries (otherthan missing material) should bedirected to the correspondingauthor for the article.

Corresponding author’s contact details: Imad Salah Ahmed Hassan, Department of Medicine 1443, King Abdulaziz Medical City, King FahadNational Guard Hospital, PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia. E-mail: imadsahassan@yahoo.co.uk

Funding: None.

Conflict of interest: None.

Ethical approval: Not required.

doi: 10.1111/j.1743-498X.2012.00584.x

� Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 397