Fairness: the hidden challenge for competency-based postgraduate medical education programs.

Competency-based medical education systems allow institutions to individualize teaching practices to meet the needs of diverse learners. Yet, the focus on continuous improvement and individualization of curricula does not exempt programs from treating learners in a fair manner. When learners fail to meet key competencies and are placed on probation or dismissed from training programs, issues of fairness may form the basis of their legal claims. In a literature search, we found no in-depth examination of fairness. In this paper, we utilize a systems lens to examine fairness within postgraduate medical education contexts, focusing on educational opportunities, assessment practices, decision-making processes, fairness from a legal standpoint, and fairness in the context of the learning environment. While we provide examples of fairness issues within US training programs, concerns regarding fairness are relevant in any medical education system which utilizes a competency-based education framework.Assessment oversight committees and annual programmatic evaluations, while recommended, will not guarantee fairness within postgraduate medical education programs, but they can provide a window into 'hidden' threats to fairness, as everything from training experiences to assessment practices may be examined by these committees. One of the first steps programs can take is to recognize that threats to fairness may exist in any educational program, including their own, and begin conversations about how to address these issues.

Enhancing competency in professionalism: targeting resident advance directive education.

BACKGROUND: Education about advance directives typically is incorporated into medical school curricula and is not commonly offered in residency. Residents' experiences with advance directives are generally random, nonstandardized, and difficult to assess. In 2008, an advance directive curriculum was developed by the Scott & White/Texas A&M University System Health Science Center College of Medicine (S&W/Texas A&M) internal medicine residency program and the hospital's legal department. A pilot study examining residents' attitudes and experiences regarding advance directives was carried out at 2 medical schools. METHODS: In 2009, 59 internal medicine and family medicine residents (postgraduate year 2-3 [PGY-2, 3]) completed questionnaires at S&W/Texas A&M (n  =  32) and The University of Texas Medical School at Houston (n  =  27) during a validation study of knowledge about advance directives. The questionnaire contained Likert-response items assessing attitudes and practices surrounding advance directives. Our analysis included descriptive statistics and analysis of variance (ANOVA) to compare responses across categories. RESULTS: While 53% of residents agreed/strongly agreed they had "sufficient knowledge of advance directives, given my years of training," 47% disagreed/strongly disagreed with that statement. Most (93%) agreed/strongly agreed that "didactic sessions on advance directives should be offered by my hospital, residency program, or medical school." A test of responses across residency years with ANOVA showed a significant difference between ratings by PGY-2 and PGY-3 residents on 3 items: "Advance directives should only be discussed with patients over 60," "I have sufficient knowledge of advance directives, given my years of training," and "I believe my experience with advance directives is adequate for the situations I routinely encounter." CONCLUSION: Our study highlighted the continuing need for advance directive resident curricula. Medical school curricula alone do not appear to be sufficient for residents' needs in this area.