“Here Be Dragons”
Note on the Lenox Globe (ca. 1503-07)
No growth or progress can occur without undergoing significant transformative change. Although we sometimes welcome and invite it, almost nothing is feared as much as deep, fundamental change. The first law of change—even when it is desired and viewed as beneficial—is that all change is resisted. Human societies resist transformative change even more tenaciously than individuals. The internal medicine graduate medical education (GME) community is no exception. In 2003, the GME community and the Accreditation Council for Graduate Medical Education (ACGME) embraced six core competencies as a model to frame the development of a physician from novice to master. ACGME convened leaders from each specialty and charged them to develop a description of the specialty-specific competencies within the six broad domains of clinical competency. Ideally, from this work, the specialties would then develop tools to systematically evaluate learner progress on each competency and the Residency Review Committees (RRCs) would harvest this research to develop measurable standards and core methods for evaluating learner achievement. Each specialty would create measurable outcomes in each clinical competency and the metrics by which RRCs would evaluate program effectiveness. Where are we today? A charitable assessment would be that we have not gotten very far and are right about where we started six years ago. So what happened?
The last six years have been filled with just enough turmoil and uncertainty that any change effort of this magnitude was destined for delay and failure. Physicians at Teaching Hospitals (PATH) audits, increased requirements for documentation, financial pressures on institutions and faculty, increased clinical productivity expectations of the faculty, the medical liability insurance crisis, and the resultant impact of risk management on the microsystems of graduate medical education as well as the need to develop and enforce a limit on resident duty hours and a concomitant threat of federal legislative and regulatory intervention have created a perfect storm to derail the move toward outcomes-based education. We find ourselves six years after the advent of the Outcome Project in general agreement on the competencies, but no further in creating educational milestones and in no common agreement on evaluation tools to measure resident achievement relative to the milestones. But there is one other underlying truth: change is hard, often terrifying and difficult. In The Heart of Change, John Kotter writes “most people do not handle large-scale change well…and that they make mistakes mostly because they have little exposure to highly successful transformations” (1).
This essay examines the dynamics of change to consider how to move the field. The Milestones Project represents a significant change for educators, accreditors, and learners alike. It is one way in which the GME leadership community in internal medicine and ACGME are expressing the tenets of competency-based evaluation and training (CBET). The milestones are a learner-centered, outcomes-oriented approach to foster and measure the learning of residents. It is a seismic shift, a transformation from the current processoriented, teaching-centric model.
Kurt Lewin developed a conceptual model for understanding the nature of change and resistance he called Force Field Analysis (Figure 1). Lewin postulated that an organization, society, or culture finds itself at any given time held in balance between forces moving the group toward change (driving forces) and forces maintaining the status quo (restraining forces). In this dynamic understanding, change occurs when the valence of driving forces exceeds that of the restraining forces, demanding a simultaneous effort to increase and highlight the driving forces as well as reduce, minimize, and eliminate the restraining forces. Force field analysis accounts for balance of power, helps identify the major stake holders, and helps identify how to engage the issues and people needed for successful transformation (3). Steps in a successful force field analysis include articulating the current situation, describing the desired situation; imagining what will happen if no action is taken; identifying the forces driving change toward the desired outcome; identifying the resistances against the desired outcome; understanding the forces (are they valid? can they be changed? which are critical?); and planning how to increase the driving forces and decrease the restraining forces (3).
Driving Forces The public appears to believe that something is amiss in GME training for physicians. The recent Institute of Medicine (IOM) report on duty hours (4) implies that the current educational environment is unsafe for patients and residents. Both IOM and the Medicare Payment Advisory Committee to Congress (MedPAC) are calling for increased legislative oversight of GME training and ACGME to assure the public that graduates have demonstrated proficiency in all domains of clinical competency. Indeed, current proposed legislation articulates and mandates dimensions of competency as components of law; the federal General Accountability Office (GAO) seeks to assess curricula and faculty ability to deliver curricula. CBET and the milestones are one way to prove our effectiveness in teaching the domains of clinical competency.
The move to a continuous dialogue is based on a desire to improve educational outcomes. Although the future system will have rules, programs will follow a more limited set of standards and accreditation will go beyond rules that govern process and infrastructure to become a system that examines and fosters high-quality educational outcomes as judged against the milestones set by each specialty. Future rules would be structured in a way that frees the creativity of the program director and faculty to maximize the benefit of the particular educational environment, while assuring RRCs and the public that the clinical education provided is producing proficient physicians.
In this new system, the accreditation cycles will be longer, potentially extending to eight to 10 years. The program requirements will be stable for longer but with the ability to modify elements if the specialty changes. Residents, fellows, and faculty will evaluate the effectiveness of their program through annual questionnaires. Faculty will continuously evaluate residents and fellows as well as periodically report their progress to RRCs through the ACGME portfolio, facilitating a comparison of the program’s performance to the specialty-specific national milestones (Figure 2). Finally, program directors and institutional officials will annually report program and institutional data to RRCs and ACGME. This new system will provide RRCs with longitudinal data to track program educational performance as well as assure the public and residents that educational outcomes are commensurate with what the profession and the public expect. It also will provide program directors national comparative information with which to judge the progressions of their residents and fellows. Should difficulties emerge in a program or sponsoring institution, RRCs will have the tools to interact with programs to facilitate timely remediation, which will prevent residents and fellows from prolonged exposure to deficiencies in the educational environment.
Restraining Forces We must also examine the forces restraining us from change and seek to minimize or eliminate them as best we can for long-lasting, effective transformation to occur. Some restraining forces are the functional barriers that any large-scale change demands: money, resources, and time, all increasingly in short supply in the turbulent health care environment of the 21st century. Most change experts agree that these barriers, while important, are more easily dealt with because they are external and visible.
However, our inner psychological landscape is filled with territory that the maps of ancient mariners used to label as the realm of “here be dragons.” Unless this territory is successfully negotiated change will not occur. Kotter states that “changing a behavior is less a matter of giving people analysis to influence their thoughts than helping them to see a truth to influence their feelings. Both thinking and feeling are essential…but the heart of change is in the emotions” (1). The nature of the fiercest dragons we encounter while trying to move towards a new state are often more related to human needs and fears than to external barriers. The need for predictability, fear of not performing, status and ego needs, low level of managing discomfort, and inconvenience make up some of the most potent restraining forces. Yet when planning and executing a change process, these forces are rarely factored into the equation.
Change, especially large-scale, transformative change such as the milestones can at a primitive but real level feel like a threat to existence. When encountering the forces in this internal area, Marvin Weisbord suggests attention to four essential areas: assess the potential for action, engage the whole system, focus on the future, and structure tasks people can do for themselves. (5)
Assessing potential for action means three things:
1. Demonstrate committed, collaborative leadership that indicates that leaders of the internal medicine GME community are willing to jump into the fray and share all the risks.
2. Set up support systems in the environment that energize and create the condition for motivation for the people most affected by the desired outcome.
3. Discover those pockets of innovation, whether individuals or systems, that already exist in the specialty to spark innovation and creativity throughout the specialty.
Engaging the whole system means involving representatives of everyone in key roles and functions who will be affected and can contribute creatively to the new future. A focus on the future is critically important. Weisbord, paraphrasing Ron Lippet, maintains that focusing on the change effort as a “problem to be solved” tends to depress a group while focusing on the future tends to inspire (5). It is less effective to highlight the current systems failures and more effective to envision a future GME system with CBET at its core and the benefits it will bring.
When all the other conditions are present, structuring tasks that people can do for themselves echoes Kotter’s sixth principle to create short-term wins that occur quickly enough “to diffuse cynicism, pessimism, and skepticism” and that build “momentum that are visible, unambiguous, and speak to what people deeply care about” (1).
ACGME is committed to taking this journey with the entire internal medicine GME community. Together, we can begin to magnify the driving forces and minimize the restraining forces that bind us. Through established educational outcomes and through resident attainment of these outcomes, the internal medicine GME community can assure the public and the residents that the GME system in the United States is graduating the finest trained physicians in the world. Despite turbulence in the health care environment and the deep-seated internal barriers to overcome, we believe that this journey is worth taking and the goals are worth attaining. Please join us on this journey.
Authors
Timothy P. Brigham, MD, PhD
Senior Vice President for Education
Accreditation Council for Graduate Medical Education
Thomas J. Nasca, MD
Chief Executive Officer
Accreditation Council for Graduate Medical Education
References
1. Kotter JP. The Heart of Change. Harvard Business School Press: Boston, MA, 2002.
2. Nickols FW. Force Field Analysis. Online. http://home.att.net/~nickols/force_field_analysis.gif. Accessed August 12, 2009.
3. Lewin K. Force Field Analysis and Diagram. Online. www.valuebasedmanagement.net/methods_ lewin_force_field_analysis.html. Accessed August 12, 2009.
4. Institute of Medicine. Resident Duty Hours: Balancing Sleep, Safety, and Supervision. Washington, DC: December 2008. Online. http://www.iom.edu/CMS/3809/48553/60449.aspx. Accessed July 31, 2009.
5. Weisbord MR. Productive Workplaces: Organizing and Managing for Dignity, Meaning and Community. Jossey-Bass Publishers: San Francisco, CA, 1991.
Citation
Brigham T, Nasca T. ACGME, Milestones, and CBET: Grieving the old world and accepting the new. Academic Internal Medicine Insight. 2009;7(3):17-19.