Anthony W. Kim, M.D.
1 How many core competencies emerged from the Accreditation Council for Graduate Medical Education (ACGME) Outcomes Project?
A 2
B 3
C 4
D 5
E 6
Ref.: 1
Comments
In 1999, the Outcomes Project of the ACGME identified six core competencies to create the framework for resident training. The overall purpose of establishing these competencies was to ensure that the trainee learned how to be competent and compassionate in treating patients. The six core competencies are (1) patient care, (2) medical knowledge, (3) practice-based learning, (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice. The ACGME implemented a 10-year time line for residencies to integrate these competencies into their training paradigms.
Answer
E
2 Which of the following specific statements is part of the patient care core competency requirement?
A Set learning and improvement goals.
B Incorporate formative evaluation feedback into daily practice.
C Demonstrate manual dexterity appropriate for the resident’s level.
D Participate in the education of patients and families.
E Communicate effectively with patients, families, and the public.
Ref.: 1
Comments
Demonstrating manual dexterity appropriate for the resident’s level is the first component of the patient care core competency. According to ACGME, residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. To meet the requirements of this core competency, residents should be able to complete the following: (1) demonstrate manual dexterity appropriate for the resident’s level; (2) develop and execute patient care plans appropriate for the resident’s level, including management of pain; and (3) participate in a program that must document a clinical curriculum that is sequential, comprehensive, and organized from basic to complex. Choices A and B are from the practice-based learning core competency. Choices D and E are from the systems-based practices core competency.
Answer
C
3 In achieving medical knowledge core competency, the ACGME states that residents will participate in an educational program that should include the fundamentals of basic science as applied to clinical surgery. This will include the elements of wound healing; homeostasis, shock, and circulatory physiology; hematologic disorders; immunobiology and transplantation; oncology; surgical endocrinology; surgical nutrition and fluid and electrolyte balance; and the metabolic response to injury, including burns. Which of the following elements is also part of the medical knowledge core competency?
A Bioinformatics and information systems in health care systems
B Wound closure techniques
C Principles of cardiac surgery
D Applied surgical anatomy and surgical pathology
E Technical aspects of a cholecystectomy
Ref.: 1
Comments
To achieve the medical knowledge core competency, residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiologic, and social-behavioral sciences and understand how this knowledge is applied to patient care. Therefore, residents should be able to perform the following: (1) critically evaluate and demonstrate knowledge of pertinent scientific information and (2) participate in an educational program that includes the fundamentals of basic science as applied to clinical surgery, including applied surgical anatomy and surgical pathology; the elements of wound healing; homeostasis, shock, and circulatory physiology; hematologic disorders; immunobiology and transplantation; oncology; surgical endocrinology; surgical nutrition and fluid and electrolyte balance; and the metabolic response to injury, including burns. Choices A, B, C, and E are not relevant to fundamental basic science knowledge.
Answer
D
4 Residents are expected to develop certain skills and habits so that they can meet all of the following goals to satisfy the criteria for the practice-based learning and improvement core competency except:
A Use an evidence-based approach to patient care.
B Participate in mortality and morbidity conferences that evaluate and analyze patient care outcomes.
C Use information technology to optimize learning.
D Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems.
E Promote the participation of their patients in a clinical trial.
Ref.: 1
Comments
For the ACGME practice-based learning and improvement core competencies, residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to develop skills and habits to be able to meet the following goals:
1 Identify strengths, deficiencies, and limits in one’s knowledge and expertise.
2 Set learning and improvement goals.
3 Identify and perform appropriate learning activities.
4 Systematically analyze practice by using quality improvement methods and implement changes with the goal of improvement in practice.
5 Incorporate formative evaluation feedback into daily practice.
6 Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems.
7 Use information technology to optimize learning.
8 Participate in the education of patients, families, students, residents, and other health care professions.
9 Participate in mortality and morbidity conferences that evaluate and analyze patient care outcomes.
10 Use an evidence-based approach to patient care.
Answer
E
5 Effectively documenting practice activities is a component of which core competency?
A Practice management
B Interpersonal and communication skills
C Professionalism
D Systems-based practice
E Practice-based learning
Ref.: 1
Comments
The ACGME indicates that residents must demonstrate interpersonal and communication skills that lead to effective exchange of information and collaboration with patients, families, and other health care professionals. Residents should be able to do the following: (1) communicate effectively with patients, families, and the public appropriate to their socioeconomic and cultural backgrounds; (2) communicate effectively with physicians, other health care professionals, and health-related agencies; (3) work effectively as a member or leader of a health care team or other professional group; (4) act in a consultative role to other physicians and health care professionals; (5) maintain comprehensive, timely, and legible medical records, if applicable; (6) counsel and educate patients and families; and (7) effectively document practice activities.
Answer
B
6 Professionalism should entail which of the following to be considered meeting the criteria for this core competency?
A Compassion and respect for others
B Autonomy during caregiving
C Accountability to patients only
D Establishing and maintaining a referral base
E Determining standards of behavior satisfying institutional requirements
Ref.: 1
Comments
Residents must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles to satisfy the criteria outlined in the professionalism core competency. Residents are expected to demonstrate the following: (1) compassion, integrity, and respect for others; (2) responsiveness to patient needs that supersedes self-interest; (3) respect for patient privacy and autonomy; (4) accountability to patients, society, and the profession; (5) sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation; (6) high standards of ethical behavior; and (7) a commitment to continuity of patient care.
Answer
A
7 Residents are expected to accomplish which of the following to meet the systems-based practice core competency?
A Understand the nuances of all health care delivery systems.
B Coordinate their patient’s care even outside their clinical specialty.
C Ensure good patient outcomes regardless of cost awareness.
D Participate in identifying system errors.
E Understand the roles of other specialists only for the purposes of patient care.
Ref.: 1
Comments
Residents should develop an awareness of the larger context of the health care system and learn to call effectively on other resources in the system to provide optimal health care to achieve the ACGME systems-based practice core competency. Residents are expected to function as follows: (1) work effectively in various health care delivery settings and systems relevant to their clinical specialty; (2) coordinate patient care within the health care system relevant to their clinical specialty; (3) incorporate considerations of cost awareness and risk-benefit analysis in patient- or population-based care (or both) as appropriate; (4) advocate for quality patient care and optimal patient care systems; (5) work in interprofessional teams to enhance patient safety and improve the quality of patient care; (6) participate in identifying system errors and implementing potential systems solutions; (7) practice high-quality, cost-effective patient care; (8) demonstrate knowledge of risk-benefit analysis; and (9) demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management.
Answer
D
8 With respect to a surgical skills laboratory, which statement is true?
A The surgical skills laboratory improves technical skills only.
B Currently, no standardized skills curriculum exists.
C Acquisition of surgical skills in the laboratory should be weighted toward the senior residency years.
D Team training should be taught in the operating room only after the junior- and senior-level resident surgical skills are learned in a surgical skills laboratory.
E The Residency Review Committee (RRC) mandates surgical skill laboratories to maintain accreditation.
Ref.: 2
Comments
As of July 2008, the RRC mandated that all surgery training programs have a surgical skills laboratory to maintain their accreditation. A surgical skills laboratory has been shown to improve technical skills and medical knowledge. The American College of Surgeons (ACS) and the Association of Program Directors in Surgery (APDS) have developed a standardized skills curriculum consisting of three phases. Phase I has modules for junior residents, phase II has modules for senior residents, and phase III has modules for team training.
Answer
E
9 Efforts to have residents develop and execute patient care plans appropriate for the resident’s level can be reinforced by:
A Negative reinforcement
B Attendance at conferences
C Didactic lecture-style format of mortality and morbidity conferences
D Decrease in the absolute number of conferences
E Increase in the absolute number of conferences
Ref.: 2
Comments
The development and execution of patient care plans appropriate for each resident’s level can be reinforced during attendance at rounds and integrated into many of the conferences that are currently available, such as morbidity and mortality conferences or grand rounds. An interactive format for the morbidity and mortality conferences has been found to improve the education value of the conference for residents at all levels. Restructuring of a morbidity and mortality conference to a more competence-based learning experience (e.g., discuss ethical dilemmas, system problems, or practice-based improvement) can enhance the educational experience. Increasing or decreasing the absolute number of conferences, per se, does not have an impact on achievement of the core competency goals.
Answer
B
10 Regarding the format of a journal club, which of the following statements is true?
A It is not actually helpful in teaching residents to critically review scientific information.
B It is a useful adjunct in surgical education, but not one of its key components.
C Participation in it can lead to improved reading habits.
D It allows the acquisition of knowledge in residency that rarely needs updating once in practice.
E Participation maintains medical knowledge in participants relative to their peer group.
Ref.: 2
Comments
The institution of a journal club can help residents learn early how to critically review the literature and is viewed as a key component of resident medical education. Residents who participate in a journal club have been shown to have improved reading habits and improved medical knowledge relative to their peers who do not participate. Other innovations such as a multifaceted Internet-based journal club can further enhance the critical reviewing ability of residents.
Answer
C
11 Identify the four steps in practice-based learning and improvement?
A Identify areas for improvement, engage in learning, apply the new knowledge and skills to a practice, and check for improvement.
B Seek knowledge, identify areas of weakness in scientific knowledge, aim to add to the knowledge, and await constructive feedback.
C Learn about new techniques, apply new techniques, refine new techniques, and individualize techniques.
D Look for improvement in current practice, observe others with a better practice model, attempt a new model in the current paradigm, and teach others the new practice model.
E Identify areas that are innovative, learn innovation, apply innovation, and teach innovation.
Ref.: 2
Comments
The four steps involved in the cycle for practice-based learning and improvement include the following: (1) identify areas for improvement, (2) engage in learning, (3) apply the new knowledge and skills to a practice, and (4) check for improvement. Learning this cycle should begin early in training so that this behavior becomes second nature as practicing surgeons.
Answer
A
12 Surgeons need to improve their communication skills with respect to palliative care. Which of the following is not such an area?
A Preoperative visit
B Intraoperative communication with the patient’s family
C Discussion of poor prognosis
D Discussion of surgical complications
E Discussion of death
Ref.: 2
Comments
The four areas in which surgeons can improve their communication skills with respect to the palliative care arena and include the preoperative visit, discussion of a poor prognosis, discussion of surgical complications, and discussion regarding death. It is imperative to the growth of the trainee as a surgeon to learn the ability to communicate compassionately. Numerous techniques are available for learning this skill and have ranged from the creation of an entire curriculum to the use of standardize patients as an instrument of training.
Answer
B
13 The consequences of poor communication are associated with:
A Decreased medical errors
B Efficient use of time and resources
C Safe patient care sign-out during shift change
D Adverse events leading to significant mortality
E Increased patient contact time
Ref.: 2
Comments
Poor communication is directly linked to delays in patient care, improper use of resources, and serious adverse events that lead to significant morbidity and mortality. Web-based systems can facilitate sign-out and lead to a better quality of sign-out, decreased time and resources in gathering objective data, improved patient contact time, and improved continuity of care.
Answer
D
14 Which of the following operations has the highest risk for preventable adverse events?
A Abdominal aortic aneurysm repair
B Coronary artery bypass graft/valve surgery
C Lower extremity bypass graft
D Hysterectomy
E Colon resection
Ref.: 2
Comments
Eight operations carry high risk for preventable adverse events, including the following: (1) lower extremity bypass graft (11%), (2) abdominal aortic aneurysm repair (8%), (3) colon resection (6%), (4) coronary artery bypass graft/valve surgery (5%), transurethral resection (4%), cholecystectomy (3%), hysterectomy (3%), and appendectomy (1.5%).
Answer
C
15 Which of the following errors represents an error in prevention?
A Inadequate monitoring or follow-up treatment
B Failure to use indicated tests
C Use of outmoded tests or therapy
D Failure to act on results of monitoring or testing
E Avoidable delay in responding to an abnormal test result
Ref.: 3
Comments
The types of errors that can occur include errors in diagnosis, errors in technique, and errors in judgment. Framed alternatively, the types of errors that can occur and be classified include errors in diagnosis, errors in treatment, errors in prevention, and other types of errors. Errors in diagnosis included those attributable to a delay in diagnosis, failure to use an indicated test, use of outdated tests or therapy, or failure to act on the results of monitoring or testing. Errors in treatment include errors in performance of an operation, procedure, or test; errors in administering treatment; errors in dose or method of administration of a drug used; avoidable delay in treatment or in responding to an abnormal test result; or inappropriate care. Errors in prevention include failure to provide prophylactic treatment or inadequate monitoring or follow-up of treatment. Other errors include failure to communicate, equipment failure, and other system failures.
Answer
A
16 As an educator, part of teaching professionalism to trainees includes demonstrating to residents how to do which one of the following?
A Develop a strong leadership style
B Manage conflicts
C Maintain a balance between surgery and life
D Continue academic productivity with a busy practice
E Understand compromises in patient welfare and financial, societal, or administrative forces
Ref.: 2
Comments
Teaching residents how to navigate through difficult situations and manage conflict is a very important aspect of professionalism. Four principles for successful conflict resolution include the following: (1) maintaining objectivity by not focusing on the participants but on the problem, (2) relinquishing the position of power and inflexibility to concentrate on individual interests, (3) creating outcomes in which both parties will have gains, and (4) making sure that there are objective criteria for negotiating the process.
Answer
B
17 Learning how to teach and become facile in systems-based practice competency can be achieved by various methods. Which of the following is an example of a method used?
A Maintaining a journal of issues discussed during quality improvement meetings and reflecting on how these issues may affect their practice of medicine.
B Using a single format (didactic or group discussion) to deliver public health policy messages.
C Leading by example in developing cost-containment efforts in the hospital in the hope that others will participate.
D Identifying problems within a specific hospital, discovering the root cause, and not ceasing until these problematic issues are resolved.
E Avoiding the inclusion of residents in hospital committees because of limited tenure at the hospital, a need to fulfill service requirements, and an obligation to uphold work hour limitations.
Ref.: 2
Comments
There are several methods for educating residents on systems-based practice learning. Such methods have included maintaining a journal of issues that are discussed during meetings and reflecting on how these issues will affect the way that the practice of medicine is carried out in the future. Other methods include incorporating a longitudinal systems-based practice into a curriculum that includes group discussion, didactic lectures, and hospital training sessions. Including residents in cost reduction efforts that entail the identification of inefficiencies, creation of improvement plans, and implementation has been shown to be educational. Standard conferences such as grand rounds, morbidity and mortality conferences, and morning reports have also been modified to teach certain principles within the systems-based practice teaching efforts.
Answer
A
18 The Institute of Medicine defined safety, specifically as which of the following?
A Implementation of preventive measures
B Freedom from accidental injury
C Zero tolerance for mistakes
D Avoidance of human errors
E Prevention of mistakes caused by a larger system
Ref.: 3
Comments
The Institute of Medicine has defined safety as freedom from accidental injury. It defined error as failure of a planned action to be completed as intended or the use of a wrong plan to achieve an objective. Safety is believed to depend on avoiding two types of errors. The first type of error is one in which the correct action does not proceed as intended, an error of execution. The second type of error is one in which the original intended action is not correct, an error in planning. It is recognized that not all errors produce harm individually. Large systems fail because recognized or unrecognized multiple faults occur together to cause an accident. An accident damages the system and disrupts the end result.
Answer
B
19 Which site or venue is the area that is at greatest risk for surgical errors?
A Operating room
B Surgical intensive care unit
C Hospital wards/floors
D Emergency department
E Ambulatory care sites
Ref.: 3
Comments
The operating room is the highest risk site for surgical errors, followed by the surgical intensive care unit, the ward, ambulatory care sites and consulting sites, and the emergency department. Therefore, considerable effort should be made to reduce processes that can facilitate errors in the operating room.
Answer
A
20 Areas with high risk for error have all but which of the following characteristics:
A Multiple individuals involved in care
B Low acuity
C Need for rapid decision making
D Instructional setting
E High volume
Ref.: 3
Comments
Areas that are at high risk for errors have similar characteristics, including multiple individuals being involved in care, high acuity, multiple distractions and interruptions, the need for rapid decisions, narrow margins for safety, high volume and unpredictable patient flow, communication obstacles, and an instructional setting.
Answer
B
21 The Joint Council on Accreditation of Healthcare Organizations (JCAHO) mandates that the time-out immediately precedes a procedure must be conducted in the location where the procedure will be performed. Documentation of a checklist created by each institution must be provided and must include a minimum of all of the following except:
A Correct patient identity
B Correct site
C Agreement on the procedure to be performed
D Specific confirmation of antibiotic administration
E Availability of correct implants and any special equipment
Ref.: 3
Comments
The JCAHO requires that correct patient identity, correct site and side, agreement on the procedure to be performed, correct patient position, and availability of correct implants and any special equipment or special requirements be confirmed before the procedure—the time-out. Confirmation of antibiotic administration, although useful, is not mandatory and is dependent on the institution. Each institution should have processes and systems in place for reconciling differences in staff responses during the time-out.
Answer
D
22 Which organization is responsible for maintaining a joint venture with the National Surgical Quality Improvement Program (NSQIP)?
A American Board of Surgery
B ACGME
C Association for Surgical Education
D RRC
E ACS
Ref.: 4
Comments
Quality of care has been examined by analyzing various indicators that can be classified into three main categories: structure, process of care, and outcomes. The National Surgical Quality Improvement Program was initially administered solely in the Veterans Administration but has now been implemented in many private sector hospitals through an alliance with the American College of Surgeons. In part, the NSQIP is designed to provide a comprehensive view of surgical quality. The ACS NSQIP focuses on the systems of care at its participating sites, not the individual provider of surgical care.
Answer
E
23 The Surgical Care Improvement Project (SCIP) differs from the NSQIP in what major difference?
A The SCIP does not partner with the ACS, but rather the JCAHO.
B The NSQIP focuses on individual providers of care, whereas the SCIP does not.
C The NSQIP focuses primarily on process measures.
D The SCIP focuses primarily on surgical outcomes.
E The SCIP focuses primarily on process measures.
Ref.: 5
Comments
The Surgical Care Improvement Project is a national partnership of organizations (including the ACS) committed to improving the safety of surgical care through a reduction in postoperative complications. Initiated by the Center for Medicare Service (CMS) and the Centers for Disease Control and Prevention (CDC), the SCIP partnership is a multi-year national campaign to substantially reduce surgical mortality and morbidity through collaboration efforts. Although the focus of the ACS NSQIP has been the measurement of surgical outcomes, the SCIP will focus primarily on process measures. The SCIP partnership is targeting areas where the incidence and cost of complications are high, including surgical site infections, adverse cardiac events, deep venous thrombosis, and postoperative pneumonia. The program will focus on surgical process measures such as the timing, choice, and duration of prophylactic antibiotic administration. It is anticipated that as the SCIP expands, additional relevant data will be included and will be in alignment with the ACS NSQIP dataset. Both the ACS NSQIP and SCIP have as their core mission the improvement of care for surgical patients. As a member of the SCIP partnership, the ACS NSQIP has developed a data collection tool to capture the SCIP measures and enable participating sites to meet the CMS SCIP reporting requirements.
Answer
E
24 What is true regarding the American Board of Surgery In-Training Examination (ABSITE)? Please select only one of the following:
A ABSITE performance has a direct correlation with performance on the American Board of Surgery Qualifying Examination.
B ABSITE scores for a program do not correlate with mandatory reading programs because it is individual resident dependent.
C ABSITE scores for a program do not correlate with focused problem-based learning education programs.
D ABSITE results are not a useful tool to gauge the general medical knowledge and patient care knowledge of surgical trainees and therefore cannot assess competency.
E ABSITE performance is inferior in evaluating trainee performance in comparison with ward (clinical) evaluations.
Ref.: 2
Comments
The American Board of Surgery In-Training Examination is one tool that has been used, in part, to try to assess the general medical knowledge and patient care knowledge of surgical trainees. It is used in conjunction with clinical (ward) evaluations and is neither worse nor better than this method of evaluation. There has been a direct linear correlation between ABSITE performance and American Board of Surgery Qualifying Examination performance (written examination). ABSITE scores have been found to be higher in programs that have established a mandatory reading program and focused problem-based learning education program.
Answer
A
References
1 . ACGME Program Requirements for Graduate Medical Education in Surgery. Available at http://www.acgme.org/acWebsite/downloads/RRC_progReq/440_general_surgery_01022008_u08102008.pdfEffective January 1, 2008. Accreditatioin Council on Graduate Medical Education. Accessed April 5, 2011
2 Liz LTH, Berger DH, Awad SS, et al. Accreditation Council for Graduate Medical Education Core Competencies. In Brunicardi FC, Andersen DK, Billiar TR, et al, editors: Schwartz’s principles of surgery, ed 9, New York: McGraw-Hill, 2010. Available at http://www.accesssurgery.com/content.aspx?aID=5012505
3 Jones RS, Way LW. Surgical patient safety. In Townsend CM, Beauchamp RD, Evers BM, et al, editors: Sabiston textbook of surgery: the biological basis of modern surgical practice, ed 18, Philadelphia: WB Saunders, 2008. Available at http://www.mdconsult.com/das/book/body/163578292-2/0/1565/113.html
4 Finlayson SRG, Birkmeyer JD. Critical assessment of surgical outcomes. In Townsend CM, Beauchamp RD, Evers BM, et al, editors: Sabiston textbook of surgery: the biological basis of modern surgical practice, ed 18, Philadelphia: WB Saunders, 2008. Available at http://www.mdconsult.com/das/book/body/163578292-2/0/1565/113.html
5 http://www.facs.org/cqi/scip.html. Accessed October 5, 2009
Instructions for online access
Thank you for your purchase. Please note that your purchase of this Elsevier eBook also includes access to an online version. Please click here (or go to http://ebooks.elsevier.com) to request an activation code and registration instructions in order to gain access to the web version.