Next Accreditation System: The Need for Separate Evaluators

摘要

The Next Accreditation System will focus graduate medical education on outcomes and competency rather than months and years.1 As we shift to performance-based evaluation of trainees, an equally important change in the faculty structure is needed. Improvement is not always a steady climb to a milestone. Dating back to Bryan and Harter's series in the 1890s on telegraph operators, studies show that new skill acquisition progresses with periods of large increases in performance interrupted by short plateaus or decrements.2,3 How, then, do we view a trainee that has a plateau or decrease in performance? Are these trainees “falling off the growth curve” and in need of remediation, or adjusting to a new skill that will take time to be perfected? Progression in overall performance may not depend on improvement of a single isolated skill. A trainee may be able to improve performance by compensating for a weakness or improving a strength. By refining strong skills while leaving weak skills weak, the trainee may be able to show improvement in the short term, but hinder his or her long-term development. However, improving a weaker skill may lead to a higher ceiling of performance at the cost of short-term plateaus and a much longer time interval before performance gains can be noticed. If performance becomes the focal point of evaluations, a trainee may choose to hide his or her weaknesses as much as possible from all evaluators and concentrate his or her efforts on short-term gains and small improvements in strengths. This may lead to a false perception that the trainee is advancing appropriately and leave little opportunity to improve weak skills during the training period. The potential for hiding weaknesses will be more likely if the same evaluator is responsible for both formative and summative feedback. A system of evaluators with a dual role would encourage the trainee to either purposefully reveal or purposefully hide weaknesses that may influence the summative evaluation negatively. One way to avoid this is to separately define mentors responsible for formative assessments and guidance from supervisors responsible for summative evaluations. While first-hand knowledge of the trainee would be crucial for both mentor and supervisor, mentors would need to keep all conversations with the trainee confidential from supervisors. Confidentiality between mentor and trainee would allow trainees to feel more free to confront their weaknesses in a safe environment without a fear of failure. Only time will tell if these will prove to be valid concerns, but a carefully designed evaluation structure may enhance the learning environment and separate any potential biases in the evaluation processes, allowing for the greatest benefits of the Next Accreditation System.