Work-hour regulations have challenged us to train residents with limited contact time. When this occurred, we were structured in a service model that utilized multiple clinical venue. By 1997, we modified a model of learning for mastery and began using it to reengineer the graduate training environment. In this process, we applied two basic educational principles to the clinical environment: Bloom's Learning for Mastery and Dreyfus's model for skill acquisition.
Bloom's Learning for Mastery is based on the concept that students are only allowed to progress from one level to the next after mastering each level completely.1 The aptitude of the learner determines the rate of progression, but time-on-task is a crucial factor. The approach has a positive impact on performance, interest in the topic to be learned, and self-confidence of the learner.
Dreyfus outlined a five-stage model for skill acquisition and described several kinds of skilled response to a situation to describe models of expertise: novice, advanced beginner, competent, proficient, and expert or master.2 We decided to set competence as a realistic outcome and used the procedural and professional expectations of the ACGME and ABS to determine the specific skills to be addressed. This training model is part of a continuous professional development program, which eventually results in mastery.
The end point of mastery is reached when the learner or practitioner has a great deal of experience, whether in practice or after fellowship. Achieving and maintaining mastery in a changing environment is a constant process. Thus, competence is the realistic end point of resident training. In this modification of a mastery-based model, the resident must show competence before he or she can advance from one level to the next. The measures of competence include: performance of the minimum standard of index cases; maintenance of a minimum level in the ABSITE; and adequate faculty evaluations of professional and clinical competence.
When we reengineered the program, we assessed our learning resources and case activity. We assigned residents to sites where those tasks were being performed. The duration of the assignment was based on the minimal standard of the index case load. The crucial considerations were: contact time; specific experiences; index case load; and shared case experiences of the faculty. We developed a resident credentialing system to signify completion of an experience and used a standards-based portfolio to document progress.
There are four major assumptions to mastery level training:3 the description of the outcomes is specifically detailed; the model provides for differences between learners; there is an opportunity to pursue personal goals; and the program includes continuous evaluation and revision. Its essential elements are criterion-referenced assessment, feedback and correctness, and congruence among instructional components.4
In our application, if the standard of competence is not met, the resident does not progress to the next level and receives an educational enhancement with remediation. Educational enhancement can include skills lab or focused mentoring, depending on the issue that is identified. If the resident still cannot meet the expectations for competence, the contract to continue training is not renewed. The biggest challenge is to identify those residents who are struggling to meet the level of competence and provide them with an educational enhancement, where the specific issues are addressed.
Each curricular assignment is integrated and may be found in various points of the curriculum. For instance, our trauma critical care assignments occur at four levels with specific goals for each experience. The PGY1 level involves basic floor care; the PGY2 is a critical care assignment; the PGY3 assignment is resuscitation and assessment; and the PGY5 is surgical intervention and management. Each assignment has specific mastery issues and procedural expectations. Each has a resident credential that signifies competence in the specific goals. The end result of this stepwise development is competence in all components of trauma care.
There are three basic components to the concept of competence: demonstration of knowledge on the ABSITE; completion of the threshold case level; and faculty assessment. Using our program's experience, we set the 20th percentile on the ABSITE as the threshold for competence. The threshold case level is based on the index case requirements. The resident cannot meet competence until all case requirements are met. Faculty assessment of resident activity is crucial since the judgment of competence is based on the observations of the faculty.
We use case experience as a guide in resident placement. We monitor the activities of both residents and faculty. For instance, if the shared case activity of a faculty member falls below 95 percent, the program evaluates both the expertise of the residents, the level of the assignment, and the participation of the faculty member. This methodology creates a situation in which resident's work with experienced faculty and the assignment includes skill sets that each resident has to master.
Although a resident could work with approximately 100 faculty members, we identify "program faculty" and request their assessment of resident performance. This process includes a site- or division-specific grading session.
This program meets all work-hour requirements and obligations. It encourages a clear career choice with good professional goals. It gives resident flexibility once the standard of case activity is met. Success is based on: the dedication of faculty who share the vision and understand the nuances of the program; the availability of reliable data that is reported promptly; the timely review of the experience and data; the skill and dedication of the coordinator; and the cooperation of the residents.
The mastery learning model has some inherent strengths and weaknesses. We have encountered challenges where the basic model did not work well and continue to modify the program to meet the basic assumptions and principles of a mastery program. These challenges include: accuracy and availability of case data; low case acquisition; overwhelming service responsibilities; inadequate attending contact; failure to meet and maintain knowledge competence; and the outcome variable of professional behavior.
All challenges have been successfully addressed by adhering to mastery learning principles and relying on the strengths of the model.
The model is challenged if case data are inaccurate or the availability is delayed. Clearly, if the number of cases were insufficient, there would be a problem. The procedure log becomes essential to the success of the strategy. It needs to be accurate and reported in a timely manner. Case-based management requires robust report generators.
The model is challenged if the case acquisition is poor for any reason. Assignment of residents to services where referral is inadequate or case diversity is poor has a significant negative impact.
The model is challenged if the time on task is jeopardized by unproductive activities or service requirements that overwhelm resident activity. Using health-care professionals to provide some service functions and limiting resident activity to educationally enhancing experiences is necessary. Assigning residents to cases or experiences that are tangential to the training mission is unproductive. The model would fail completely if time for educational enhancement is limited or caseload is insufficient. It is necessary to modify the model to have set time limitations since training time is limited.
The model is challenged when faculty do not have sufficient contact to realistically and reliably evaluate the resident. It does not work well if the evaluation system for faculty, residents, or clinical assignments is inadequate or delayed. Performing evaluation functions online is an efficient way to gather information.
The model is challenged when the outcome variable is demonstration of knowledge. Using the ABSITE as the "gold standard" is both attractive and reasonable. However, remediation of inadequate knowledge and exit strategies if remediation fails are more difficult to design and apply. The demonstration of knowledge during resident recruitment and a minimal performance standard are crucial to the success of this model.
The model is challenged when the outcome variable is professional behavior or communication skills. Setting specific outcome variables and documentation of experiences that demonstrate failure to achieve competence are difficult to achieve. Faculty development strategies to improve mentorship, feedback, and documentation are necessary for success. Further, prioritizing resident assignments to faculty who possess the ability and interest is very important.
Future challenges include: changes in practice or site of procedure; ambulatory nature of the experience; insufficient caseload or faculty referral; lack of faculty participation; definition of competence; and patient safety. As the technology changes, success will be based on a skills laboratory where basic skills can be taught, while ensuring patient safety. This maintains the value of the time-on-task for procedural experience by transferring some of the training to other environments.
In our experience, the model works because we addressed or are addressing all challenges, have recognized opportunities, and developed coping strategies. Outcomes are specifically detailed by both ACGME and ABS guidance. At the senior level, the model has sufficient flexibility that differences between residents can flourish. Compliance with work-hour regulations provides the opportunity to pursue personal goals. An excellent coordinator with standards-based portfolio and reliable database provides continuous evaluation and revision.
Mastery training has been identified as a basic surgical residency program model.5 We are reporting our experience in using a mastery model of training to meet all needs. It is a tool in an overall strategy of development. It is a dynamic process that needs constant attention. The program continues to evolve. When the ACGME proposed the core competencies, we modified the program to include all competencies in the basic standards.
In a mastery program, the manager needs to:
- Identify and prioritize tasks or procedures
- Determine the sites where the procedure is performed
- Set a minimum standard of experience for competence
- Develop a reliable method of data acquisition
- Evaluate the site and the faculty
- Follow the experience
- Manage the program according to procedural experiences
- Modify sites and procedures as needed
Crucial issues include:
- Managing recruitment
- Minimizing service activities
- Maintaining adequate experience and assessment
- Documenting progress
- Developing educational enhancement and remediation experiences with an exit strategy for those who do not show competence
Time-on-task is crucial. In the basic mastery-training model, the learner continues to participate in the educational activity until mastery is reached, regardless of the time required to do so. Surgical training has both time constraints and experience standards. Unlimited time is not practical or economically feasible. Ultimately, the success of the model will depend on the development of: a skills lab to improve the value of the clinical contact time; a definition of clinically relevant competence; and reliable tools that measure competence.
Mastery of the art and craft of the specialty should be the goal of every surgeon. Application of mastery learning principles is appropriate in a surgical residency. Demonstration of competence is the most reasonable end point of any residency. Utilizing the mastery level principles in the training environment is the ultimate challenge.
- Bloom BS. Learning for Mastery. In: B S Bloom, ed. All Our Children Learning. McGraw-Hill; 1968/81.
- Dreyfus HL. Intuitive, deliberative, and calculative models of expert performance. In: Zsambok, CE, Klein, G, eds. Naturalistic decision making. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc; xix, 414.
- Livingston JA, Gentile JR. Mastery Learning and the decreasing variability hypothesis. Journal of Educational Research 1996; 90:67-74.
- Guskey TR. The essential elements of mastery learning. Journal of Classroom Interaction 1987; 22:19-22.
- DeRosa D, Bell RH, Dunnington GL. Residency program models, implications, and evaluation: Results of a think tank consortium on resident work hours. Surgery 2003; 133:13-23.