We are facing the most far-reaching development in graduate medical education in the last 50 years—this is effectively turning around everything we have ever known. The mission of the Accreditation Council on Graduate Medical Education (ACGME) is to improve the quality of health care in the United States by ensuring and improving the quality of graduate medical education experiences for physicians in training. The ACGME is a totally voluntary system with no governmental involvement. What the ACGME does now is to measure the potential in a program; we rate programs on a descriptive basis. In measuring a program using competencies we now want to ask if the residents achieved the learning objectives set by the program. Establishing competencies involves objectives, organized curriculum, and evidence that the program really achieves its goals.

In 1997, the ACGME embarked on The Outcome Project, a revolutionary, long-term initiative to enhance residency education through residency outcome assessment, and by June 2001, the program requirements were in place. The ACGME general competencies now apply to all the specialties in American medicine. The field of psychiatry is being challenged to develop its own core competencies; now the field of addictions must also begin to develop its own core competencies.

It is expected that between mid 2006 and mid 2011, the competencies will be fully integrated with learning and clinical care. This Initiative is designed to answer the following questions:

• What is the value of a competency-based model of education?
• How can we implement the competencies?
• How can we assess the competencies?

The current model of evaluating graduate medical education is descriptive, focuses on structure, and measures potential by asking such questions as:

1. Does the program comply with the requirements?
1. Does the program have established goals and objectives and an organized curriculum?
2. Does the program evaluate its residents and itself?

The revised model measures accomplishment and strives to enhance residency education through outcomes assessment. It asks such questions as:

1. Do the residents achieve the learning objectives set by the program? (instead of "Does the program comply with the requirements?")
1. What evidence can the program provide that it does so? (instead of "Does the program have established goals and objectives and an organized curriculum?")
2. How does the program demonstrate continuous improvement in its educational processes? (instead of "Does the program evaluate its residents and itself?")

This dramatic shift will continue to look at structure but the very important outcome measurements will be added. The ACGME Outcomes Project is based on several principles:

1. Whatever we measure, we tend to improve!
1. Measurement of outcomes allows more flexibility to be creative. An endpoint is identified; multiple paths may be chosen to arrive there.
2. Measurement of outcomes provides more public accountability.

To identify the general competencies for all of American medicine, more than 2,500 articles were reviewed and an initial list of 84 competencies was developed. After thorough review and extensive vetting by the Residency Review Committee (RRC) members, program directors, residents, corporate leaders, university presidents, and the public, six general/core competencies were identified for all of medicine. There was considerable financial support from The Robert Wood Johnson Foundation.

The shift to competency-based graduate medical education levels the playing field across medicine. In addition to these core competencies, specialty (and subspecialty) specific competencies may be added. The six core competencies for all of medicine are:

1. Patient care—This means that patient care is compassionate, appropriate, and effective for both the treatment of health problems and for the promotion of health.
1. Medical knowledge is defined as knowledge about established and evolving biomedical, clinical, and cognate (epidemiological and social-behavioral) science and knowledge of application of this to patient care.
2. Practice-based learning and improvement is defined as the investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.
3. Interpersonal and communication skills result in effective information exchange and teaming with patients, their families, and other health professionals.
4. Professionalism is manifested through a commitment to carry out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations.
5. Systems-based practice is manifested by actions that demonstrate awareness of and responsiveness to the larger context and system of health care and an ability to effectively call on system resources to provide optimal care.

Addiction psychiatrists will deal with the six core competencies when they take re-certification examinations. The core competencies have opened up dialogue among various professional associations in the field.

Once the six core competencies for all of medicine were identified, the ACGME began to develop measurement tools. In conjunction with the American Board of Medical Specialties (ABMS), a toolbox was developed that includes:

1. A 360^o evaluation instrument
1. Chart Stimulated Recall Oral Exam (CSR)
2. Checklist evaluation of live or recorded performance
3. Objective Structured Clinical Exam (OSCE)
4. Procedure, operative and case logs
5. Patient surveys
6. Portfolios
7. Record review
8. Simulations and models
9. Standardized oral exams
10. Standardized patients
11. Written exams

Addiction psychiatry is in the early stages of this process, identifying the core competencies for the subspecialty. Input is sought on what are the appropriate competencies for addiction psychiatry keeping in mind that there are only six for all of medicine. This input must focus on the essence of addiction psychiatry and be measurable. After the initial responses to the core competencies for addiction psychiatry are received, a draft document will be produced and circulated for broad input. This will occur by June 2002. It is recommended that some method of assessing learning in each of the core areas be proposed as well.

Some key questions that arise early in the process are:

• Where do we start? Build on what you know.
• What are the costs? Opportunity and dollars begin to replace process and structure measures with outcome measures. Look for mastery.
• Neither my faculty nor I know how to do this, now what? Learn from each other; share across disciplines and share resources.

A Zen quote that should guide the process is "Quality isn’t something you lay on top of subjects and objects like tinsel on a tree…it is the core from which the tree must start." More extensive information on competencies and outcome assessment can be found by visiting the Web site of the ACGME at www.acgme.org and select Competencies and Outcomes Assessment from the menu on the left side of the screen.