The University of British Columbia

• Observation as an Evaluation Tool
• Effective Evaluation

Resident Benchmarks (a.k.a. Bordage Model)

Over the past three years, on reviewing the evaluations that we receive from residents and community preceptors, it is obvious that both groups would appreciate some guidance in what the expectations should be at the different stages of the two year Family Practice Residency Program. Further inquiry shows that there are widely differing expectations by the preceptors of the residents at the beginning of the Residency in terms of knowledge base, doctor-patient relationships, formulating differential diagnoses and knowledge of appropriate investigation and treatment , to name just a few.

There are also discrepancies in the degree of autonomy granted a resident at all stages of the program, some preceptors allowing residents freedom to make and abide by their decisions from the outset and others reluctant to allow a resident any autonomy even at the end of the residency.

A review of the literature seeking answers to these problems reveals that, although there are lists of competencies that it is desirable that residents should acquire, there appears to be no practical outline of what a residency program should expect at the different stages of a resident’s career allowing for different levels of maturity of a resident and differing styles and teaching of preceptors.

Over the last ten years, the Resident Benchmark document has been available for Preceptors for review and to ascertain if their Family Practice residents are meeting the standards expected at different points in their residency training. Since its inception there have been changes in the Redbook requirements and many changes in approaches to teaching and learning. This requires that the Benchmark Document be up-dated and more contemporary information made available to our teachers. However, many of the initial concepts are as valid as they were ten years ago and bear repeating.

What prompted the initial document were the discrepancies in the degree of autonomy granted at all stages of the residency with some preceptors allowing a large degree of freedom to make decisions regarding patients from the outset and others unwilling to trust residents’ decisions even at the end of the residency training. How some residents were treated depended on the teaching style of the preceptor and the perceived maturity of the resident. It was felt that a more uniform approach was needed so that the residency proceeded smoothly and all residents and preceptors were familiar with the expectations of the UBC Family Practice Residency Program.

This amended document is intended to give preceptors some practical guidelines on what to expect at the different stages of the residency and how to allow residents increasing autonomy as their confidence grows and their ability to diagnose, investigate and treat patients is documented.

This outline is a first attempt to give some guidelines which will be useful to new as well as experienced faculty. Comments and criticism are welcome.

We have attempted to link the resident’s progress to the educational model of Bordage with which many of you are now familiar. This helps us understand how residents are processing information and how they use it to formulate medical decisions. Not all residents will be at the same stage at any given time in their career but it helps us, as educators, to more accurately gauge the residents’ progress.

BORDAGE STAGES

I)          Reduced Knowledge

Never learned anything about a particular subject or once knew it and cannot for whatever reason recall it.

II)         Scattered or Dispersed Knowledge

Has some knowledge of a topic but it is only partial or sometimes inaccurate. Not enough recall to be able to make reasoned decisions but beginning to have a grasp of some subjects.

III)        Elaborated Knowledge

Now has a sufficiently well developed knowledge base and can accurately work through an educational algorithm and make informed and usually accurate decisions.

IV)       Compiled Knowledge

Very quick to see to the heart of a problem. Pattern recognition of illness presentations allows for accurate and confident diagnosis and rapid decision making. The mark of a seasoned and confident clinician.

Beginning of First Year of Residency

Resident Abilities  (Bordage I or II)

• Able to take a history and perform a physical examination. However, expect a hospital based style; prolonged, mechanical, unfocused and takes more than half an hour to complete.

• Large gaps in knowledge base especially in relation to commonly seen family practice problems. Unable to differentiate common symptoms from uncommon ones since those seen in hospital practice are skewed.
• Little deductive ability since symptoms are common and disease is not.
• Scant knowledge of therapeutics including drugs and therapies let alone knowing what therapies are likely to influence outcomes.
• Often does not articulate awareness of psychosocial or contextual issues of patients.
• Conversely, medical school education may have focused on the psycho-social approach to the neglect of other competencies.

Responsibilities & Goals Of Resident

• Need to familiarize themselves with family practice type of problems.

• Consult with preceptor on each case.
• Constantly review how investigations help to determine the management  of current problems. Not all investigations need to be done at once; learning concept of step-wise approach.
• Learn to recognize that problems are undifferentiated and often are not solved at first or even subsequent visits. 
• Getting comfortable with uncertainty.
• Becoming aware of the long-term relationship with patients and the importance of family relationships.
• Acquiring effective communication skills, including both verbal and non-verbal cues given by the patient.
• Learning how to give succinct and accurate precis of the pertinent clinical findings to the preceptor.

Response of Preceptor Over First Six Months of Residency

• Introduce the resident to your record system and the way you document patients’ histories and office visits. If you have an Electronic Medical Record system, ensure that the resident is taught how to access and operate it.
• Early, observe complete history and examination until comfortable that resident shows appropriate and consistent skills.
• Allow resident to watch you perform procedures such as minor surgery, pelvic exams and IUD insertions then give the resident the opportunity to do these procedures under your supervision. Observe resident doing several pelvic exams.
• Thereafter, observe at least part of the histories and selected examinations once daily or more often if warranted at this level of training.
• Look for the resident becoming at ease in greeting patient and being able to initiate the interview.
• Allow lots of time for interviewing, half to three-quarters of an hour.
• Encourage resident to explain thinking patterns and how differential diagnoses are entertained. Ask “What else did you consider”
• Encourage resident to make a most likely diagnosis in each case and the reasons, i.e., make a commitment. Ask “What do you think is going on”.
• Emphasize the merits of the SOAP record keeping, with particular stress on the Assessment so you can see the resident’s pattern of thinking.
• Emphasize common and most likely diagnoses.
• Tell them what they did right and how that impacts the patient.
• Correct mistakes.
• Encourage resident to read around cases and use the Internet, then  report back to you the results of their enquiries.
• Stress the acquisition of a professional approach, appropriate boundary setting and when and where revealing personal information is helpful therapeutically.

END OF FIRST SIX MONTHS

Resident Abilities. (Bordage II)

• Histories are crisper and better use is made of the patient record and the resident is more comfortable with focused examinations.
• Growing comfort with the patient population and the recognition of people as people, warts and all and the fact that everyone needs professional long-term health care.
• Better appreciation of range of common problems seen in family practice.
• Less likely to consider esoteric diagnoses at first contact.
• Increased ability to demonstrate empathy and active listening.
• More rational use of investigations.
• More familiarity with pharmacotherapeutics but still large gaps in knowledge and often irrational choice of drugs for family practice.

Responsibilities & Goals of Resident

• Increased understanding of range of problems dealt with in family practice.
• Building up a group of patients who have been seen on several occasions and who are happy to see the resident on a long term basis.
• Early understanding of disease and illness patterns in family practice.
• Better understanding of psychosocial issues in illness presentation.
• Beginning to see opportunities for counseling on preventative strategies.
• Still uncertain of own ability to manage family practice problems but less intimidated than six months previously.
• Still  dependent on preceptor to make most decisions.

Response Of Preceptor - Six Months to One Year into Residency

• Still need to discuss each case with resident but inter-actions briefer and more focused.
• Acknowledgment that relationship with resident still often patient -driven and most patients want to maintain their connection to you, their family doctor.
• Allow resident an increasing share in decision-making re patient care.
• Remain  vigilant for gaps in knowledge and encourage resident to read and consult guidelines. Do they know how to do this quickly and efficiently? Don’t assume all residents are highly computer literate.
• Spend time in discussing preventative care and indicate where resident can take the initiative in broaching the topic.
• Review exam technique and watch resident interview intermittently.
• Probe for understanding and appreciation of psychosocial aspects of patients’ experience of illness/experiences.
• Have a system in place whereby resident reviews all tests ordered by them and handles phone calls by patients they have seen.
• Resident needs to understand billing procedures and be billing for patients seen by them.
• Watch for some residents becoming over-confident and over-estimating ability.
• Review record keeping. It should be exemplary by this stage. To protect yourself legally, residents should sign all entries and have it counter-signed by you. Alternatively, have the resident write that the case was discussed and with whom.
• Preceptor should have a good appreciation of a resident’s ability. Any misgivings should be discussed with the resident’s educational advisor or the program director.

 END OF FIRST YEAR

Resident Abilities (Bordage II-III)

• Very comfortable with the family practice setting.
• Good rapport with patients.
• Able to conduct an interview within half an hour.
• Listens well and able to prioritize patient needs/issues.
• Cues into “Red Flag” signs and symptoms.
• Able to formulate a reasonable management plan.
• Still tends to over-investigate.
• Much better grasp of therapeutics, but still needs lots of mentoring.
• Should have respectful relationships with office staff and recognize them as a resource to the physician and the patients.
• Able to confidently and reliably deal with lab results, consultations with specialists, phone calls and requests for medication refills.
• Growing awareness of community resources.

Responsibilities & Goals of Resident for Next Six Months.

• More aware of weaknesses in the knowledge base and beginning to organize electives to remedy them.

• Recognition that one person cannot carry all the knowledge needed to be effective. Must have an organized approach to accessing knowledge and information.
• Now feels can accept increasing responsibility for patient care.
• Wants increasing autonomy from preceptor in handling patients.
• Still reliant on preceptor in many cases for help with patient care.

Preceptor Response One Year to Eighteen Months into Residency

• Gradual relinquishing of teacher/learner role and increasing collegial relationship as resident matures. Period of consolidation.
• Should now be fully integrated into the practice on-call system.
  Allowing resident increasing autonomy in interview situation and less supervision as merited.
• Allows resident to make some decisions regarding patient care even if preceptor is not in full agreement, so long as patient well-being is not compromised.
  Maintains regular feedback both positive and negative.
• Keeps time available for resident to discuss cases and soliciting  help.
• Regular review of cases at end of day especially the problematic cases and where more detailed discussion is needed.

 END OF EIGHTEEN MONTHS

Resident Abilities (Bordage III)

• Should be seeing patients at a comfortable rate every fifteen minutes and no more than 20 minutes for a regular appointment.
• Where it is not possible to deal with all the patients concerns, able to prioritize and arrange to see patient at another appointment without patient feeling short changed.
• Able to see patients alone and make therapeutic decisions in most cases.
• Still needs to consult preceptor over more difficult problems.
• Good appreciation of limitations.
• More comfortable in challenging preceptor over diagnosis and management.
• Manages challenging interactions with effective communication skills and self awareness.

Responsibilities & Goals of Resident

• Eager to be well prepared for the CCFP exam.
• Seeking skills in areas of Family Medicine that are deficient or where there is a particular interest.
• Spending more time to complete research project.
• Increasingly aware of the business aspects of entering practice. Spends more time with practice manager or MOAs to see how they do their job.
• Wants to assume responsibility for decision-making for patients’ visits as much as possible.

Preceptor’s  Response Eighteen Months to Two Years of Residency

• Comfortable in allowing resident to manage care of patient in office.
• Ensuring  resident manages time effectively and copes with pressures of day to day practice.
• Increasingly, contact with some patients limited to ensuring that the patient knows that you are still their doctor and will maintain continuity of care.
• Most of the interaction with the resident is on a collegial basis.
• Comfortable with asking resident’s advice on difficult cases.
  

END OF TWO YEARS OF RESIDENCY
Resident Abilities (Bordage IV, but at least iII) 

• Resident has demonstrated competency through practicum.
• Able to manage office practice, lab and other paperwork, on-call and in-patient responsibilities.
• Interacts with patients and colleagues at the level of a new locum
• Resident has been asked to do a locum for you.
• Preceptor looking forward and prepared to do the whole thing over again with another resident.
• Sadness at seeing resident leave your practice

Clinical acumen (CA)

CA1.   Identify the purpose(s) for the visit.* (PGY-1)

CA2.   Develop appropriate biopsychosocial hypotheses that apply to the presenting problem. (PGY-1)

CA3.   Conduct a focused evaluation of the presenting problem (including history, physical examination, and laboratory/radiological procedures) (PGY-1)

CA4.   Appropriately prioritize the probable and potential diagnoses to ensure that attention is given to the most likely, most serious, and most readily treatable options. (PGY-1)

CA5.   Present a provisional and working diagnosis to the patient. (PGY-1)

CA6.   Develop a plan of action that attends to salient medical, psychosocial, family, cultural and socioeconomic issues. (PGY-1)

CA7.   Implement the negotiated management plan. (PGY-2)

CA8.   Inquire into and discuss sensitive issues that may impact on the execution of the negotiated management plan. (PGY-2)

CA9.   If indicated, assist the patient in arranging for appropriate medical and ancillary referrals that seek to resolve specific issues in the diagnostic or management arenas. (PGY-2)

CA10. Arrange for follow-up of the current problem that fits the guidelines of current standard of care and/or attends to the special needs of the patient, family, or caregiver. (PGY-1)

Interpersonal skills (IS)

IS1.     Conduct an encounter that recognized the primacy of patient needs and treats the patient as an appropriately equal health care partner. (PGY-2)

IS2.     Conduct an interview in a manner consistent with the values of family medicine using appropriate verbal and nonverbal skills. (PGY-2)

IS3.     Conduct an interview that fosters an adequate and helpful doctor-patient relationship. (PGY-1)

IS4.     Work together with clerical staff and nursing staff in a manner that fosters mutual respect and facilitates an effectively run practice. (PGY-2)

IS5.     Work together with partners, fellow family physicians, specialists and other health care professionals in a manner that fosters mutual respect and facilitates the effective handling of patient care issues. (PGY-2)

Organizational skills (OS)

OS1.   Incorporate the principles and practice of health maintenance into each patient care encounter, where appropriate. (PGY-2)

OS2.   Review the biopsychosocial problem list at each visit and attend to appropriate longitudinal care issues. (PGY-2)

OS3.   Conduct the visit in a time-efficient and professional manner. (PGY-2)

OS4.   Complete the tasks of the patient care session so that all necessary duties (including telephone messages, charting, administrative tasks, patient care) are accomplished in a timely, organized, and professional manner. (PGY-2)

OS5.   Completely document the patient care encounter in the medical record in a concise and legible manner following a problem-oriented format and using the SOAP (or generally accepted) notation. (PGY-1)

OS6.   Update the  problem list and medication list at each visit. (PGY-1)

Business principles (BP)

BP1.   Learn how the office functions and the roles of the MOAs and business or book-keeping  personnel. (PGY2)

BP2    Bill medical plans or patients  appropriately for services rendered. (PGY-1)

Personal and professional growth and development (GD)

GD1    Engage in continuing medical education activities that are influenced by interest, deficiency, and need. (PGY-2)

GD2.   Engage in activities that will foster personal and professional growth as a physician. (PGY-2)

*Visits might occur in the outpatient office, hospital, nursing home, home, etc.

SOAP - subjective data, objective data, assessment, plan.

(Modified from Competency-Based Education in Family Practice,, Hershey S. Bell, Stanley M. Kozakowski, Robin O Winter, Family Medicine Vol. 29, No. 10, November-December 1997)