Schemes for facilitating competency-based training, diagnostic labeling and immediate therapeutic interventions.

1. Frameworks
for education
Models for enhancing
competency-based
training and contextual
clinical decision making
Imad Hassan, Department of Medicine, King Abdulaziz Medical City, King Fahad National
Guard Hospital, Riyadh, Kingdom of Saudi Arabia
New models of
teaching and
resident staff
training are
needed
SUMMARY
Background: In the era of quality
care, competency and outcomebased education, new models of
teaching and resident staff training are greatly needed. These
should be based on adult learning
principles and allow for highquality, patient-centred, evidence-based care.
Context: Three areas that need
restructuring with specific conceptual frameworks to allow for
seamless competency-based
training, and also to assist in
putting the decision-making
process in context, are: case or
topic presentation; diagnostic
labelling; and immediate
interventions for front-line caregivers.
Innovation: Three models are
proposed: the competencystructured presentation (CSP)
model; the bedside clinical
diagnosis, etiological cause and
severity score diagnostic labelling
(BESD) model; and the symptomatic, supportive, specific, specialty and site of care (5S) model.
Implications: The models listed
above may assist in the following
domains of patient care. In a
competency-structured presentation, the CSP model formalises
case presentations and discussions in a competency-based
structure, thereby supporting the
392 Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397
development of a competencyfocused thought process for
patient care. The BESD and 5S
models improve the understanding of patient problems within the
appropriate context, and thus
assists in achieving the following
quality outcomes. The BESD model
promotes better diagnostic labelling, thereby assisting in implementing individualised, evidencebased interventions. The 5S model
promotes the cognitive conceptualisation of medical management, which will aid a more
comprehensive, patient-centred,
multidisciplinary care input,
thereby reducing process errors
and improving outcomes.

2. INTRODUCTION
Q
uality of care and competency-based training are
two intimately linked
concepts.1
Quality of care
The Institute of Medicine has
defined quality of care as ‘the
degree to which health services
for individuals and populations
increase the likelihood of
desired health outcomes and are
consistent with current professional knowledge’.2 Six outcomes
are emphasised: patient safety;
patient centredness; effectiveness; efficiency; timeliness; and
equity. These are geared towards
the prevention or reduction of
the six ‘D’s of patient care
outcome: death; disease; disability; discomfort; dissatisfaction; and destitution (cost of
care). Evidently, health care
systems, and especially the staff,
must be specifically empowered
with all the knowledge and skills
necessary to attain these
outcomes.
Competency-based training
Unfortunately, old-style resident
training is unlikely to equip the
trainees with all the necessary
skills for such a comprehensive
look at patient care. New ‘resident competencies’ beyond simple clinical skill building are
clearly necessary. Unavoidably,
new structures and processes for
resident staff training, particularly in the active clinical decision process, need to be put in
place to achieve these outcomes.
The move by medical training
bodies in America, Europe and
elsewhere to restructure their
accreditation programmes is a
direct consequence of this.3–5 In
all of these programmes, outcome-based, competency-directed training frameworks were
emphasised. The CanMeds framework (Table S1) is an excellent
example of such a programme.3,4
It explicitly states that for a
practising physician to be fully
New ‘resident
competencies’
beyond simple
clinical skill
building are
clearly
necessary
competent, he or she must be
proficient in seven domains of
knowledge and skill. These socalled meta-competencies include
competencies as a medical expert, communicator, collaborator,
scholar, advocate, manager and
professional. However, details of
generic concepts to allow for a
seamless incorporation of these
competencies into everyday
practice are not always explicitly
outlined.
Novel, friendly strategies to
train and empower front-line
staff, reduce inefficiencies in the
care process and improve patient
outcomes are needed. The three
proposed models below may help
in realising some of the aforementioned competencies by making them part of the routine in
resident education, and in decision making when formulating a
management plan for a specific
patient. They may thus equip
residents with strategies to manage patient complexities and
uncertainties, reduce process
errors and ultimately achieve the
desired quality outcomes.
The proposed models are primarily based on the author’s long
experience in medical staff training in clinical care and in mechanisms to enhance the
implementation of evidencebased medicine.
A COMPETENCYSTRUCTURED
PRESENTATION (CSP)
MODEL, USING THE
CANMEDS FRAMEWORK
Classically, and for educational
purposes, both undergraduates
and postgraduates present clinical
topics in a narrative or case-based
style. In both of these, classic
headings that are used include
definitions, etiology, epidemiology, clinical presentation, differential diagnosis, investigations,
therapy and prognosis etc. This
form of presentation does not
explicitly emphasise the new
domains of knowledge or skills
necessary for quality of care, as
outlined above, or empower the
trainees with all the competencies
outlined by CanMeds, or similar
bodies, for comprehensive, outcome-based training and patient
care. A proposed scheme for topic
presentation is outlined below.
Topic headings are now deliberately portrayed under competency
headings. Presumably, this conceptual framework or map would
assist in realising a more competency-directed clinical training
and decision-making process, and
in drafting a comprehensive,
high-quality management plan for
every patient. Practical, patientcentred care actions and interventions may thus be incorporated in the clinical decision
process. Table S2, available online, depicts the presentation
outlines for two common medical
topics, namely stroke and bronchial asthma. It compiles all the
necessary knowledge and skills
under the CanMeds competencybased educational framework.
Once completed, the exercise
would have emphasised to the
trainees and residents all of the
concepts that are conducive for
comprehensive, multidisciplinary,
quality care. It is vital to highlight here that active training in
relevant practical skills is an
essential component of the exercise: e.g. training residents in
Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 393

3. Failure to
consider the
precipitant or
cause will
inevitably
result in
deficient care
inhaler technique or in peak flow
meter recording, in the example
of bronchial asthma, which are
skills not normally included in
old-style lectures.
CONCEPTUAL FRAMEWORK
FOR COMPREHENSIVE
GUIDELINE-FRIENDLY
DIAGNOSTIC LABELLING:
THE BEDSIDE CLINICAL
DIAGNOSIS, ETIOLOGY,
SEVERITY DIAGNOSTIC
(BESD) MODEL
So often, when residents are
asked for their clinical diagnosis,
an incomplete and clearly seriously deficient label is given. In
my opinion this hinders proper,
comprehensive, guideline-based,
therapeutic interventions, with
an unmistakable negative impact
on the quality of care. For
example, labelling a patient with
an exacerbation of bronchial
asthma or heart failure, as such,
without explicitly including the
probable precipitant and degree
of severity (and therefore the
necessity for admission to hospital or an intensive care ward)
will hinder appropriate guideline-directed immediate care,
and also any additional interventions needed to reduce the
duration of stay, the cost of care
and the future use of the health
care system. With this in mind,
residents must be trained on
unequivocally including the following three essential elements
in any diagnostic label given to
any one patient: the bedside
clinical diagnosis; the etiological
or precipitating cause; and the
severity score or grade. Table 1
Table 1. The bedside clinical diagnosis, etiological
cause and severity score diagnostic labelling (BESD)
model: comprehensive, guideline-friendly diagnostic
labelling
Case scenario 1
A 64-year-old hypertensive and diabetic patient presenting with
breathlessness. Clinically in pulmonary oedema, with gallop and crackles up
to his upper chest posterioly and blood pressure of 80 ⁄ 60 mmHg.
Electrocardiogram and cardiac enzymes confimed an acute ST -elevation
myocardial infarction.
Bedside clinical diagnosis
Etiological diagnosis or
precipitant
Severity
Acute left heart failure
and pulmonary oedema
Acute myocardial
infarction
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. Urine
confirmed the presence of ketonuria and uncountable pus cells. Plasma
glucose, 630 mg ⁄ dl; ABG revealed a pH of 7.3; bicarbonate 18; anion
gap 11.
Bedside clinical diagnosis
Etiological diagnosis or
precipitant
Severity
Diabetic ketoacidosis
Urinary tract infection
Insulin therapy
non-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
394 Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397
gives two examples. In addition
to the clinical diagnosis, a failure to consider the precipitant
or cause will inevitably result in
deficient care and a poorer outcome. Moreover, the appropriate
evidence-based interventions for
optimising the outcome will be
different for acute coronary
syndrome or diabetic ketoacidosis,6,7 with regard to the sites of
care and recommended interventions, e.g. admission to the
Coronary Care Unit and a strategy of immediate interventional
revascularisation, for the patient
with the acute coronary syndrome.
A CONCEPTUAL
FRAMEWORK FOR PATIENTCENTRED, COMPREHENSIVE,
IMMEDIATE THERAPEUTIC
INTERVENTIONS: THE 5S
MODEL
Similar to the discussion above
for diagnostic labelling, when
asked about treatment, residents
have a tendency to jump to
specific therapeutic interventions, without paying much
attention to important, patientcentred inputs. Such interventions may at times be as
important as the disease-specific
therapeutic interventions themselves. Apart from the latter,
there are at least four other
therapeutically indispensable
interventions that the decisionmaking process must incorporate
as part and parcel of the management plan. These include:
symptomatic care; supportive
care; specialty ⁄ subspecialty
involvement; and decisions on
the most appropriate site of
care. Symptomatic treatment is
important, as it directly alleviates patient discomfort. Regrettably, action to relieve symptoms
is not commonly initiated by
medical staff. An excellent
example is the use of analgesics
in the acute-care setting: socalled oligoanalgesia.8 Supportive care to reverse physiological
complications before damage

4. becomes irreversible, and until
the precipitant is brought under
control by its specific intervention, may be life saving. Guidelines unambiguously dictate the
sites of care for specific disease
severity scores, e.g. patients
with community-acquired pneumonia with a CURB-65 (Confusion, Urea, Respiratory rate,
Blood pressure-65 age in years)
score of three or more must be
managed in intensive care, as
opposed to the general ward.9
Similarly, specific high-severity
indices for patients with acute
asthma exacerbation entail the
need for higher levels of care.10
Likewise, guidelines recommend
early specialty or subspecialty
referral for specific acute illnesses, e.g. gastroenterology and
endoscopy referral for patients
with haematemesis and specific
severity scores, etc. Cognitive
conceptual deficiencies in the
decision making of junior staff
have been shown to be an
important cause for poor outcome in the acute care setting.11
Training residents on routinely,
conceptually constructing or
outlining their management plan
along the 5S framework may thus
assist them in recognising several of the goals of quality care.
Two examples depicting the
utility of the 5S framework for
front-line caregivers in the acute
setting are presented in Table 2.
It is gratifyingly evident that
the BESD and 5S conceptual
models incorporate all seven
domains of the CanMeds competency skills. In my opinion, the
successful application of these
models hinges on a resident who
is highly skilled in most, if not
all, of the aforementioned competencies. For example, skillful
diagnostic reasoning and severity assessment requires a competent ‘medical expert’,
subspecialty referral envisages
collaborative care, with the
communicator, advocate and
professional roles being indispensable for comprehensive,
patient-centred care.
Figure 1 depicts the interrelationship of the BESD, 5S and
CSP models, especially in the
acute care setting.
TESTING THE BESD AND 5S
MODELS
In an exercise to test the usefulness of the above models, 21 year1 residents and interns were
randomly presented with one of
two case scenarios. One was of a
64-year-old patient with acute
myocardial infarction (as presented in Table 1) and the other of
a 70-year-old man with community-acquired pneumonia (as presented in Table 2). Trainees were
requested to outline their likely
diagnosis and their immediate
therapeutic interventions on an
answer sheet. Once completed,
the same case scenario was resubmitted to the trainee, but this
time the answer sheet was
restructured to conform with the
above two models. The two answer
sheets were then compared with
regards to the explicit inclusion of
the various domains of case diagnosis and management, as outlined in the two models. Apart
from the symptomatic, supportive
and specific therapeutic inputs,
which were relatively comparable
Guidelines
unambiguously
dictate the sites
of care for
specific disease
severity scores
Table 2. Two examples depicting the utility of the symptomatic, supportive,
specific, specialty and site of care (5S) model for guiding therapy for front-line
caregivers in the acute setting
Case scenario 1
A 70-year-old, smoker presenting with fever, pleuritic chest pain and breathlessness. Clinically, confused, temperature
39.6°C, systolic blood pressure 80 mmHg, respiratory rate 32 ⁄ minute and PaO2 on room air of 54 mmHg. Radiology
confirmed a diagnosis of multilobar community-acquired pneumonia.
Specific care
Specialty ⁄
subspecialty care
Symptomatic
care
Supportive care
Analgesics
Antipyretic
Intensive care team
Oxygen therapy
Intravenous antibiotics that
Intravenous fluids chosen are based on severity ⁄ referral
Inotropes
site of care: e.g. ceftriaxone
and moxifloxacin, with
additional antipseudomonal
cover
Site of care
Intensive care unit,
as the CURB-65
score is 4.
Case scenario 2
A 17-year-old single, female with a painful sickle cell crisis. Clinically, drowsy, dehydrated and in pain. Haemoglobin
45 g ⁄ l. Chest X-ray revealed bilateral infiltrates.
Symptomatic care Supportive care
Analgesics
Specific care
Antibiotics
Oxygen
Exchange transfusion
Hydration
Simple transfusion
Specialty ⁄ subspecialty Site of care
care
Haematologist
Intensive care Pain
service
Intensive care
Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 395

5. The aim of [this
integrated
model]is to
empower
residents with
applicable
conceptual
frameworks for
quality care
be a manifestation of a lack of an
internalised cognitive conceptual
framework for patient care.
Proper Diagnostic
Labeling
CONCLUSION
Clinical Diagnosis
Etiological or
Precipitating Cause
Severity Score
Immediate
Airways/Circulation
Checks
Emergency
Pa ent
Interven ons
Emergency &
In-Pa ent
Interven ons
Medical
Expert
Symptomatic
Care
Communicator
Professional
Site of
care
PatientCentred
Care
Speciality/
Sub_specialty
Referral
Supportive
care
REFERENCES
CompetencyBased Care
Collaporator
Scholar
Specific
care
Manager
Advocate
Figure 1. The bedside clinical diagnosis, etiological cause and severity score diagnostic labelling
(BESD), the symptomatic, supportive, specific, specialty and site of care (5S) and the competencystructured presentation (CSP) models for patient care
R1 Residents & Interns (n = 21): Pre & Post Change in
Management Decisions
Post
120.0
Percentage
Pre
71.4%
71.4%
80.0
90.5%
60.0
40.0
57.1%
57.1%
19.0%
0%
0.0
Clinical
Etiologic
Diagnosis Diagnosis
100%
57.1%
20.0
Severity
Indication
Site of
Care
8.3%
Special
Referral
Figure 2. Trainees pre- and post-change in management decisions
before and after, albeit improved
(85.7 versus 95.2%), all other
domains significantly improved
(Figure 2). This confirms that
deficiencies in diagnostic labelling and in management decisions
are not necessarily the result of a
lack of knowledge, but are likely to
396 Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397
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or clinical topic discussions
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SUPPORTING
INFORMATION
version of this article at http: ⁄ ⁄
onlinelibrary.wiley.com ⁄ doi ⁄
10.1111/j.1743498X.2012.00584.x ⁄ suppinfo
Table S1. The CanMeds
competencies.3
Table S2. The competencystructured presentation (CSP)
model: topic presentations;
applying the CanMeds roles.
Please note: Wiley-Blackwell
are not responsible for the
content or functionality of any
supporting materials supplied by
the author. Any queries (other
than missing material) should be
directed to the corresponding
author for the article.
Additional supporting information may be found in the online
Corresponding author’s contact details: Imad Salah Ahmed Hassan, Department of Medicine 1443, King Abdulaziz Medical City, King Fahad
National 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
Ó Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 392–397 397