Clinical Competence in Internal Medicine AMERICAN BOARD OF INTERNAL MEDICINE*; Philadelphia, Pennsylvania
entific and technologic successes of recent decades with the empathic care of the patient. Progress in technology may complicate the relationship between the patient and physician. Therefore the personal and caring relationship takes on even greater significance.
To describe more explicitly the components of competence required of the internist, The American Board of Internal Medicine has analyzed the medical encounter and defined the major variables involved: the abilities required of the internist, the tasks that must be performed to solve a medical problem, the medical illness, and the patient. The abilities of the internist have been categorized into attitudes and habits, interpersonal skills, motor and technical skills, and intellectual abilities. The latter have been further subdivided into the abilities to acquire and use knowledge, to organize, to synthesize information, and to apply clinical judgment. For each of these abilities statements of clinical competence that rebate to the tasks required have been developed. The Board is publishing this paper, an excerpt of a longer document, with the hope that it will be useful to residents, faculty, and practicing internists. [This article is an abridgment of a document with the same title that is being published concurrently by The American Board of Internal Medicine. Requests for copies of the unabridged document, "Clinical Competence in Internal Medicine," should be addressed to The American Board of Internal Medicine, 3624 Market Street, Philadelphia, PA, 19104, USA—The Editor] THE
AMERICAN
BOARD
OF
INTERNAL
MEDICINE
has
p r e v i o u s l y d e s c r i b e d (1) its c o n c e p t of t h e ideal i n t e r n i s t : A general internist is a physician who provides scientifically based, empathic care for the nonsurgical illnesses of adults. This care tends to be characterized by a mutual personal commitment between doctor and patient, by stability over time, by substantial breadth, by availability, and by an appropriate attention to elements of human support, sensitivity, and concern. It is marked by technical sophistication and major professional expertise. The general internist functions as a consultant to other specialists and is competent to handle critically ill patients and nonsurgical disorders in adolescents and adults seeking aid in the emergency room setting. Well-trained internists are unique in their ability to deliver with broad competence primary, secondary, and, in some instances, tertiary care. The general internist provides continuing, comprehensive care for common and complex multisystem illnesses in the ambulatory as well as the hospital setting. The internist serves as the patient's advocate and accepts responsibility for all the patient's health needs, obtaining assistance from other specialists and from allied health professionals as required. One of the hallmarks of the general internist is a continuing personal interest in the patient. The practice of internal medicine requires the knowledge and application of advances in the science and technology of medicine. The internist provides care that combines the sci• F r o m the American Board of Internal Medicine; Philadelphia, Pennsylvania. • T h i s document was prepared by the Board's Committee on Evaluation in General Internal Medicine: John A. Benson, Jr., M.D.; Alfred J. Bollet, M.D.; Saul J. Farber, M . D . (co-chairman); Daniel D. Federman, M . D . ; Wallace N . Jensen, M.D.; Lynn O. Langdon; William L. Morgan, M.D.; Donald E. Olson, M . D . (co-chairman); F r a n k A. Riddick, Jr., M.D.; and George D . Webster, M . D .
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To translate the qualities thus described into explicit components that will be useful in examining the process of certification and recertification, the Board established a Committee on Evaluation in General Internal Medicine charged with defining the knowledge, skills, and attitudes to be expected of the certifiable internist. The report of the committee, accepted by the Board in 1977, has been useful in several ways. It has served as a foundation for a more explicit statement by the Board of the goal of certification: "to provide assurance that the Diplomate possesses the knowledge, skills, and attitudes essential to the provision of excellent care in internal medicine" (2). It has helped in a reappraisal of the certification and recertification process. It has been used to evaluate and modify the Board's written examinations. It is now being used to modify the recommended procedures for evaluating candidates by training program directors. Because of the potential usefulness of the report in defining the practicing internist to organizations outside the Board, and after consultation with representatives of various organizations in or related to internal medicine, the committee's report has been revised to its present form as published here. Internal Medicine
Internal medicine is the major clinical science central to all the specialties of medicine and surgery that deal with the health and illness of adolescents and adults. In the mastery of this science, the internist must understand health and disease in relation to the totality of human behavior, physiology, and pathology. Internal medicine requires the constant correlation of clinical science with the basic and behavioral sciences. The internist should understand the life processes of normal cells, organs, and the human organism; the variability of these processes; and their abnormalities that lead to dysfunction and disease. New facts and concepts that emerge from research in the biologic and clinical sciences must be applied to the care of patients. This never-ending process is an integral part of the clinical competence of the internist. The cornerstones of the discipline of internal medicine and the other clinical sciences are the intellectual ability to conceptualize normal and abnormal biologic processes of the human body and the skills of clinical observation
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©1979 American Board of Internal Medicine
that lead to the ability to diagnose illness. The words of Flexner (3) regarding differential diagnoses and the construction of clinical hypotheses are as meaningful today as they were in 1910: The main intellectual tool of the investigator is the working hypothesis. The scientist is confronted by a definite situation, he observes it for the purpose of taking in all the facts. These suggest to him a line of action. He constructs an hypothesis. Upon this he acts, and the practical outcome of this procedure refutes, confirms or modifies his theory. Between theory and fact his mind flies like a shuttle; and theory is helpful and important just to the degree in which it enables him to understand, relate and control phenomena. This is essentially the technique of research: Wherein is it irrelevant to bedside practice? The physician too is confronted by a definite situation. He must seize its details, and only powers of observation trained in actual experimentation will enable him to do so. The patient's history, conditions, symptoms form his data. Thereupon, he too, frames his working hypothesis, now called a diagnosis. It suggests a line of action. Is he right or wrong? Has he actually amassed all the significant facts? Does his working hypothesis properly put them together? The sick man's progress is nature's comment and criticism. The professional competency of the physician is in proportion to his ability to heed the response which nature makes to his ministrations. The progress of science and the scientific and intelligent practice of medicine employ, therefore, exactly the same technique. Recent studies of the process of medical inquiry (4, 5) support Flexner's view. From the opening statement by the patient the physician begins a process of conceptual thinking that is often initially subconscious or automatic but leads to the formulation of hypotheses as to the nature of the problem. As data are accumulated and the hypotheses become better defined, efficient problem-solving habits lead to a reiterative, conscious matching of the information being elicited to information stored in the internist's memory. This matching process results in more directed data gathering designed to confirm or refute the hypotheses. For example, when a patient presents with generalized edema, likely initial hypotheses are that the problem is related to a disorder of the heart, the liver, or the kidney. An equally acceptable alternative set of hypotheses might be that the problem is either an expansion of extracellular volume or an abnormal distribution of extracellular volume. With these hypotheses, most internists begin the diagnostic process by predicting findings that would be expected and directing inquiries or physical examination or diagnostic procedures to check for the presence of the predicted findings; the resulting data support or refute the hypotheses or suggest new ones. This process continues until the medical problem is Table 1. Problem-Solving Abilities of the Internist Attitudes and habits Interpersonal skills Motor and technical skills Intellectual tools and abilities Knowledge Knowledge of pathophysiology Other medically related knowledge Organization Synthesis Clinical judgement
Table 2. Problem-Solving Tasks Data gathering History taking Physical examination Diagnostic study Diagnosis or problem definition Medical care Immediate Continuing resolved. After a diagnosis is reached, knowledge of the disease process must be integrated with knowledge of the patient and the environment to develop an optimal plan for treatment. As the results of therapy are observed, a need to acquire additional data, change the diagnostic hypothesis, or alter therapy may become apparent. The internist will constantly relate and integrate observed findings to knowledge learned previously through education or experience. This sequential hypothesis-testing approach to the diagnostic and therapeutic problem-solving process is more efficient than the accumulation of data without purpose, a process in which all of the data collected are reviewed at one time in the hope of recognizing a diagnostic pattern. The latter approach is highly prone to error, inefficient, and costly and lacks the conceptualization that is fundamental to understanding the illness of patients. The described sequential hypothesis-directed approach to problem solving should be highly developed in the internist. The internist's training should provide the environment and models to develop the necessary habits and abilities required. The evaluation of clinical competence should assess the degree to which the skill has been developed. Components of the Medical Encounter
In the hypothesis-directed approach to problem solving in a medical encounter, many different pathways or sequences could lead to equally acceptable solutions to the problem. However, some pathways or components are common to each encounter. Definition of these components and their interrelations allows the development of a system describing those functions of the practice of internal medicine that are the competencies to be taken into account in the education and evaluation of internists. This system is similar to that developed by The American Board of Pediatrics (6) and that described by Reichman (7). Each medical encounter contains at least four variables. I. The abilities the internist needs in resolving a medical problem: knowledge, skills, and attitudes. II. The tasks or functions that the internist must perform to resolve the medical problem: data gathering, problem definition, and therapy. III. The medical illnesses or health status of the patient: disease and factors important to health maintenance. IV. The patient; this variable includes not only a patient's physical response to disease process, but also facABIM • Clinical Competence
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Table 3. General Attitudes and Habits
The internist should 1. Have as his primary concern the welfare of his patients. 2. Provide comprehensive and continuing care to his patients using his and other sources of expertise as may be required to alleviate as much as possible all of his patient's health problems. 3. Be sensitive to the patient as a person and to his emotional, cultural, social, and physical needs. He must be able to accept the anxiety, fears, hostility, and anger that his patients may exhibit and accept responsibility for the patient's care without bias or prejudice. 4. Be accessible for his patients' needs and provide coverage by peers when he is unavailable. 5. Recognize his limitations and be willing to consult with other physicians when necessary, making appropriate use of their advice. He should not undertake management of a diagnostic or therapeutic procedure he is not qualified to do unless circumstances indicate that all alternatives carry greater risk. 6. Accept responsibility for educating patients or their families, or both, regarding problems, management plans, and decisions. 7. Use technologic restraint by avoiding diagnostic or therapeutic measures that are unnecessary or present undue risks. 8. Minimize the cost of medical care to the patient. 9. When acting as a consultant be appropriately thorough to identify medical problems other than those for which the patient was rpfprrpH 1 C1C11 C U .
10. When acting as a consultant, accept the responsibility for maintaining appropriate communication with the referring physician and support the referring physician-patient relationship unless the patient's welfare is jeopardized. 11. Participate in the continuing education of students, residents, peers, and other health personnel according to his ability. 12. Participate according to his talents in the solution of health care problems in the community and society. 13. Devote the interest, time, and energy required to maintain and upgrade his clinical knowledge and skills. 14. Understand the limitations of current medical knowledge in explaining all aspects of a patient's problems. tors such as personality, socioeconomic status, and cultural, family or other environmental factors. Although many patient variables are of a scope and complexity that preclude their analysis in this document, this variable is important because the patient frequently affects the function of the internist and the outcome of the medical encounter. PROBLEM-SOLVING ABILITIES
The abilities of the internist are those needed to use the hypothesis-directed process described. Although it is difficult to identify all the discrete abilities required for the complex process of a medical encounter, they can be helpfully categorized into four major components (Table 1): attitudes and habits, interpersonal skills, motor and technical skills, and intellectual abilities. The intellectual abilities can be further subdivided into a hierarchy like that of the cognitive levels described by Bloom and associates (8). These abilities are complex and often overlapping. For any particular task several or all levels of abilities might be involved. For example, in evaluating a patient with an unknown type of liver disease, the internist may decide that a liver biopsy is indicated after considering knowledge of the indications and possible complications of the procedure. Interpersonal skills may be important in gaining the patient's cooperation and motor skills are needed
to obtain a satisfactory specimen with the least danger and discomfort to the patient. Finally the biopsy findings are organized with other knowledge of the patient's illness and synthesized to reach a diagnostic or management decision. Attitudes and Habits: The standards of behavior to which the internist should be committed in clinical practice. Some of the desirable attitudes and habits to which an internist should be committed in practice are not held solely by the profession but, rather, are those valued by all of society. Further, any of the specific attitudes or habits referred to in this document are not unique to the internist, but because of their importance to the internist, they deserve emphasis here. These attitudes and habits have been set forth within the initially stated description of the internist, and they are stated in behavioral terms in the section, "Statements of Clinical Competence." In addition to integrity and ethical behavior, they can be summarized as four qualities: willingness to take responsibility for the whole care of the patient; comprehensiveness and thoroughness in care; empathy for the patient that helps to alleviate discomfort and anxiety; and scholarship that maintains the intellectual skills needed for clinical competence. Interpersonal Skills: The communication abilities, verbal and nonverbal, required of the internist to interact
Table 4. General Interpersonal Skills
The internist should have the interpersonal skills to 1. Develop a strong relationship that inspires confidence in patients and conveys a feeling of interest and concern. 2. Communicate to patients and patients' families information about diagnosis, prognosis, and management. 3. Interact in a nonjudgmental manner. 4. Be alert to and interpret nonverbal clues from the patient. 5. Recognize and be attentive to the patients' emotional needs and recognize their potential influence on the symptoms and course of the ill
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6. Educate the patient in health maintenance. 7. Communicate with and inspire cooperation with other members of the health care team. 8. Communicate effectively and tactfully with colleagues both as a consultant and as a member of the health care team. 404
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Table 5. Competence in History Taking
In obta;ining a medical history from a patient, the internist should (Attitudes and habits) 1. Develop the habit of completing and recording a complete history. 2. Be sensitive to symptoms or statements which suggest depression or psychosomatic illness. 3. Develop the habit of updating and supplementing historical data on follow-up visits. 4. Pursue with appropriate thoroughness all historical clues. (Interpersonal skills) 5. Be able to establish rapport with the patient and other informants that makes possible the obtaining of a complete and accurate history. 6. Be able to recognize verbal and nonverbal clues from the patient and pursue the indicated lines of inquiry. 7. Be able to adapt language appropriately to ensure communication with persons of differing ethnic, cultural, or nationality backgrounds. 8. Be able to adapt to patients who present a disjointed or disorganized history. (Motor and technical skills) 9. Be able to use techniques, such as body posture and eye contact, that facilitate communication. (Knowledge) 10. Have depth of knowledge that allows a thorough exploration of symptoms relating to the patient's problem. 11. Have depth of knowledge that allows consideration of various etiologies to explain the patient's symptoms. (Pathophysiology) 12. Understand symptoms in terms of altered structure and function of body systems. 13. Differentiate between symptoms that arise directly from a disease process and those that occur as a result of the body's response to disturbed homeostasis. (Organization) 14. Approach the history in a logical, directed way to ensure completeness. 15. Follow-up medical clues in a directed, logical pattern. 16. Organize and record the history completely in a fashion that will be understandable to all potential users of the record. (Synthesis) 17. While obtaining history, integrate symptoms into diagnostic hypotheses. 18. Recognize symptom patterns that suggest even low-frequency diseases. 19. As additional data are obtained, be able to formulate new or additional diagnostic hypotheses. (Clinical judgment) 20. Assess the reliability of the history obtained. 21. Separate appropriately irrelevant from relevant information. 22. Identify information that seems incongruous with the clinical situation.
effectively with other persons during the practice of medicine. The people with whom the internist must be able to communicate include the patient, patient's family, and other physicians and members of the allied health team. Skills in interpersonal relations are important to provide understanding, establish an appropriate patient-physician relationship, give the patient confidence, and provide effective care continuously. These communication or interpersonal skills include the ability to elicit accurate information and evaluate its reliability, communicate factual information clearly, and know how to respond to nonverbal communication. Such skills include the ability to recognize the individuality of each patient and the uniqueness of each situation. Different skills may be needed when the internist is functioning as a consultant rather than as a primary physician. Motor and Technical Skills: The learned manual or psychomotor skills necessary to perform physical examinations and other diagnostic and therapeutic procedures. The most basic of these skills are those needed to do a directed yet comprehensive physical examination. This skill is essential for all internists. Although possession of this skill has been assumed by some training-program faculty and evaluators, competence in this area is often lacking. Although some deficits are the result of the lack of appropriate habits, many are the result of the failure to develop sufficient motor or sensory skills to elicit or
detect subtle findings. Other motor skills are needed to perform various procedures. These range from the basic procedures such as venipuncture, lumbar puncture, and thoracentesis to more complex procedures such as liver or kidney biopsy, insertion of intravascular catheters for monitoring, pericardiocentesis, and peritoneal dialysis. The technical procedures the internist performs will be determined by the kind of practice, personal preferences, local custom, the availability of other skilled professionals, and local delineation of privileges. Each physician has to take responsibility for developing proficiency in those procedures performed. Intellectual Tools and Abilities: A variety of intellectual abilities are required for the internist to proceed through the reiterative problem-solving sequence. The intellectual processes used to solve medical problems is much more complex than implied by a list of five intellectual abilities. Identification of some intellectual abilities can, however, be a useful aid in understanding the process used in medical problem solving. In general, the intellectual abilities of clinical judgement and synthesis are more complex than knowledge and organization; however, the abilities are neither unique nor unrelated, and they overlap to a large extent. Knowledge: The store of information or facts pertinent to particular diseases or illnesses and the ability of the internist to apply that information in the clinical setting. ABIM • Clinical Competence
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Table 6. Competence in Physical Examination
In doing a physical examination the internist should (Attitudes and habits) 1. Develop the habit of doing a complete physical examination unless inappropriate to the clinical situation. 2. Pursue appropriately all abnormal physical findings. (Interpersonal skills) 3. Be able to encourage the patient's cooperation so that a complete physical examination is possible. 4. Undertake the physical examination with concern for the patient's comfort, privacy, and sensitivity, forewarning the patient of uncomfortable or unanticipated maneuvers. (Motor and technical skills) 5. Be able to elicit subtle as well as obvious physical findings by inspection, percussion, palpation, or ausculation and be able to use appropriate instruments such as the ophthalmoscope, tonometer, and sigmoidoscope. 6. Be able to modify physical examination procedures to adapt to particular medical situations. (Knowledge) 7. Know the range of normal variation of physical findings. 8. Know alternative techniques capable of confirming abnormal findings. (Pathophysiology) 9. Have a knowledge of anatomic relations. 10. Have knowledge of the physical or physiologic mechanisms that produce normal and abnormal physical findings. 11. Understand and use physiologic maneuvers that can elicit findings that would otherwise not be apparent. (Organization) 12. Proceed through the physical examination in an orderly fashion to ensure completeness. 13. Record the physical examination systematically so that it will be understandable to all potential users of the record. (Synthesis) 14. Integrate physical findings, normal or abnormal, with the diagnostic hypotheses suggested by history or other data. 15. Recognize patterns of findings that confirm diagnostic impressions or suggest new diagnostic possibilities. (Clinical judgment) 16. Be able to judge the significance of borderline abnormal findings. 17. In the presence of multiple diseases, assign findings to the appropriate disease process. 18. Be able to judge how often and to what extent a physical examination should be repeated on a given patient. This category includes the general information, or set of facts and relationships, an internist learns from formal education, textbooks, journals, and clinical experience. These facts may be easily recalled by memory or they may be stored in a variety of resources and retrieved by reference. The internist needs to kow facts of various kinds. In addition to empiric knowledge of diseases, knowledge is required of epidemiology, psychology, sociology, and so on. Central to this body of knowledge is knowledge of the basic medical sciences as they relate to disease. Because of the importance of this subset of knowledge, it is emphasized in this document by giving it a separate heading, "Pathophysiology.' * Pathophysiology: The knowledge of the medically related basic sciences. This category includes knowledge of the normal state as well as knowledge of the way in which biologic systems are altered by disease. Knowledge of pathophysiology can be retained in the internist's memory or retrieved from reference sources. The importance of this category derives from the conviction that the internist, in order to have complete understanding of the significance of clinical findings, should relate them to basic principles of altered structure and function. This full knowledge and understanding makes possible medical decisions that are most relevant, and prognoses that are most accurate, and allows detection of unexpected or aberrant findings. This knowledge provides direction and meaning to clinical decisions. Organization: The ability to systematize clinical data and related knowledge in a medically logical, directed, and purposeful manner. 406
The ability to organize is the capacity to combine findings so that their sequence and relation are evident. Manifestations of this ability include the presentation of a concise oral or written summary of pertinent data, the development of a logical and sequential diagnostic and therapeutic plan, and the development and maintenance of interpretable records over time. Synthesis: The process of combining all of the relevant pieces of information and constructing from them an integrated concept. After pertinent clinical data have been arranged into an ordered pattern, clinical problem solving requires a synthesis of these data to make sets of findings meaningful. Synthesis is the essence of diagnosis or problem definition. Although synthesis has many levels and components, there are two that are useful to distinguish: pattern recognition and integration. Pattern recognition is identification of a set of related components that is recognized as a previously learned entity. Integration is a combination of complex data in such a way as to apply several concepts or principles to reach a conclusion that was not initially apparent. Although the distinction between these two may be easy in many circumstances, in others it is difficult. An internist may be required to integrate complex data when a problem is presented the first time; however, with the experience of observing similar data repeatedly, part of the process of synthesis becomes one of pattern recognition. Clinical Judgment: The ability to make clinical decisions based on the assignment of appropriate values to a set of facts or to a synthesis of a set of facts. This category represents the ability of the physician to
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Table 7. Competence in Diagnostic Study
In ordering or performing diagnostic procedures the internist should (Attitudes and habits) 1. Use the laboratory mainly to confirm or refute diagnostic hypotheses. 2. Accept responsibility for using most effective and least risky procedures that minimize cost of health care. 3. Be able to accept responsibility for ordering potentially risky or costly procedures that are essential for the solution of a patient's problem. (Interpersonal skills) 4. Be able to explain to patients the purpose, possible complications, and factors necessary to make the procedures comfortable, safe, and interpretable. (Motor and technical skills) 5. Be technically proficient in the performance of those procedures undertaken. (Knowledge) 6. Know the range of biologic variation in test results. 7. Know the indicated procedures including special or unusual studies. 8. Know the diagnostic specificity and limitations of laboratory studies. 9. Know how to perform or order test procedures in a manner most likely to ensure interpretable results. 10. Recognize invalid test results. (Pathophysiology) 11 Understand the underlying rationale of the indicated procedures. 12. Interpret the results of procedures in terms of alterations in underlying pathophysiology. 13. Recognize laboratory results that reflect homeostatic responses to disease in contrast to those that reflect the effect of disease. (Organization) 14. Order laboratory studies in a logical sequence to avoid unnecessary procedures or costs and observe appropriate timing of procedures to avoid invalidating test results. 15. Record laboratory findings in a logical, organized fashion. (Synthesis) 16. Accurately interpret test results. 17. Recognize patterns of diagnostic information. 18. Integrate data appropriately to confirm or refute diagnostic hypotheses. (Clinical judgment) 19. Select from alternatives those diagnostic procedures with the greatest likelihood of useful results, taking into account risk and cost. 20. Make appropriate judgments from conflicting laboratory results. 21. Adapt diagnostic procedures to meet the special requirements of the medical situation. 22. Discern when indicated procedures should be delayed, as in an emergency. 23. Judge the validity and reliability of laboratory studies in each clinical situation. choose selectively and wisely among alternative diagnostic and therapeutic possibilities. The internist does this by evaluating these possibilities as they relate to a particular clinical situation. Examples of clinical judgments include determining the appropriate balance of risk and benefit of alternative courses of action or inaction, making value judgments in each situation with respect to the need for thoroughness as contrasted to efficiency, and establishing priorities for the allotment of resources. It also includes the evaluation of facts or theories that appear in the medical literature. In each of these examples the internist, drawing from a variety of information and experience, must weigh pertinent factors and make a conscious decision. PROBLEM-SOLVING TASKS
The elements or events within the complex process that occurs in a clinical encounter are difficult to describe and arrange systematically because differences of style, perspective, or experience may result in an infinite variety of sequences that lead to the same solution and are equally acceptable. However, there are common elements or tasks in the process that can be identified. These tasks need not be done in a particular sequence; the sequence of tasks will differ with the person doing them and the medical problem being evaluated. The categories of tasks that describe the problem-solv-
ing process are described in Table 2. Implied in each of these categories is not only the overt activity involved (for example, interviewing the patient, doing a physical examination, ordering laboratory tests) but also the internist's understanding and interpreting of the information relating to the patient's illnesses. History Taking: The acquisition of a chronologic, medically logical description of pertinent events in the present illness, the past medical history, family history, and social history; the review of systems; the review of patient medical records; the acquisition of in formation obtained from the family and other sources and information available from other written and nonverbal communications. Included in this task is the correlating of the internist's knowledge of those disease(s) suggested by the patient's symptoms with information concerning the patient. This correlation and integration of knowledge with facts are needed to create a directed, logical history. Physical Examination: The elicitation of findings from an appropriately thorough examination of the patient that documents the presence or absence of signs or abnormalities that are relevant to the pertinent health problems of the patient. The patient's physical findings must be correlated with those expected or unexpected in the hypothesized disease(s). Diagnostic Study: The appropriate selection and accurate interpretation of laboratory or other diagnostic proABIM • Clinical Competence
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Table 8. Competence in Diagnosis or Problem Definition
In reaching decisions about patients and their medical problems, the internist should (Attitudes and habits) 1. Develop the habit of relating as much as possible the clinical situation of a patient to the total body of knowledge and experience in medicine. 2. Consider explanations for all of the clinical findings obtained. 3. Develop the habit of considering psychologic disease as a possible explanation of a patient's symptoms. 4. Strive for the most definitive diagnosis for each problem. 5. Carefully consider diagnostic possibilities suggested by patients or other sources of information. (Interpersonal skills) 6. Be able to express clearly to patients and families facts about the diagnosis that will ensure their understanding and cooperation. (Mot(or and technical skills) 7. Not applicable. (Knowledge) 8. Consider all the diagnostic possibilities that might explain the data obtained. 9. Possess knowledge of the manifestations of the likely causes of the patient's disease. 10. Be able to link the clinical findings to knowledge of the natural history of disease such as epidemiology, course, complications, and prognosis. (Pathophysiology) 11. Express diagnoses in terms of altered structure and function where appropriate. 12. Be able to explain in pathophysiologic terms the relation between the diagnosis and the presence or absence of symptoms, signs, or findings. 13. Be able to apply established and emerging concepts in the basic medical sciences to clinical problem solving. (Organization) 14. Obtain and record data including appropriate negative information, knowledge of which is indicated by the nature of the disease present. 15. Record diagnoses in a logical fashion in the medical record. 16. Discuss the patient's diagnoses and problems in progress notes in an organized and complete fashion. 17. Record all appropriate diagnoses and problems in the medical record to ensure adequate follow-up. 18. Be able to present a patient's problems to consultants or other personnel in an organized, logical fashion. (Synthesis) 19. Use knowledge of disease processes to integrate data obtained into diagnostic hypotheses. 20. Recognize clusters of signs and symptoms associated with particular disease entities. 21. Use all data in making final diagnostic decisions. 22. Recognize unusual or aberrant findings as they relate to the diseases under consideration. 23. Recognize low-probability diagnoses suggested by the findings. 24. Recognize manifestations of psychologic disturbances. 25. Be able to diagnose the presence of multiple or complex interacting disorders. (Clinical judgment) 26. Develop final diagnostic formulations by evaluating all available data and information. 27. Be able to make diagnostic decisions when necessary in the absence of complete data. 28. Use available data from the literature or other sources as an aid to assessing the importance of conflicting findings. 29. Be able to revise or suspend judgements when acute new complications or findings of illness occur. cedures that are indicated from the internist's knowledge of the patient and the suspected condition(s). Diagnosis or Problem Definition: The decision regarding the diagnosis(es) or differential diagnosis that is specific enough to permit the formulation of a management plan. In the data-gathering process, the internist will develop a number of diagnostic hypotheses, based on a store of knowledge concerning the natural history of the diseases under consideration (etiology, epidemiology, prognostic probabilities, and so on) and other facts known about the patient. Some of these hypotheses will be rejected as a result of directed data gathering. At some point, the internist will integrate all of the available information and make a decision or decisions directed toward management of the illness. One can collect data exhaustively; a competent internist knows when to formulate a diagnosis and implement a plan of management. Medical Care: The preventive or therapeutic activities that are designed to maintain health and modify, alleviate, or resolve the patient's problems, including those of a personal or emotional nature. A decision not to treat may be an appropriate management plan. For this document, 408
management has been subdivided into two categories, immediate care and continuing care, to emphasize some of the activities included in the latter category. Immediate Care: Emergency or acute medical care. Immediate care is arbitrarily defined as that initiated promptly or within the first few days or weeks of a patient's problem; the need for care is expected to be of limited duration. Continuing Care: Prolonged care through weeks, months, or years dictated by the nature of the patient's problem. Continuing care is expected to be of long duration but may have to be started immediately. Included are the activities associated with maintenance of health or preventive medicine, patient and family education, measures directed toward the risk factors of disease, modifications of life style or environment where indicated, anticipation of complications, and appropriate followup of the patient with re-evaluation of health problems. T H E MEDICAL ILLNESS
The term illness is used, rather than disease, to emphasize the fact that when a disease occurs in a person the
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Table 9. Competence in Medical Care: Immediate and Continuing
In prescribing medical care, the internist should (Attitudes and habits) 1. Provide comprehensive and continuing care to his patients whenever appropriate, taking into account pertinent socioeconomic factors. 2. Accept the responsibility to see that all sources of expertise are used to ensure the best outcome of all the patient's health problems. 3. Refer to others the management of patients requiring technical therapeutic procedures that the internist may not be qualified to perform. 4. Resist patient demands for inappropriate therapy. (Interpersonal skills) 5. Be able to educate patients and families adequately to ensure compliance with immediate and continuing management plans. (Motor and technical skills) 6. Be proficient in those therapeutic procedures requiring technical skills. (Knowledge) 7. Know the most effective therapies available for the problems. 8. Know the correct procedures for instituting the indicated therapy. (Pathophysiology) 9. Have knowledge of interactions between drugs and the need to modify drug therapy in the presence of specific organ dysfunction. 10. Understand the mechanisms of drug action and the acute and chronic side-effects. (Organization) 11. Document thoroughly all therapeutic plans. 12. Organize available resources to ensure patient compliance, including patient education. 13. Establish monitoring procedures to assess patient compliance and the results of therapy. 14. Inform and instruct all health professionals involved in the care of the patient of the details of the therapeutic plans. 15. Arrange for long-term follow-up and care, including rehabilitation. (Synthesis) 16. Devise a therapeutic plan that considers all the patient's active, treatable problems. 17. Recognize signs and symptoms indicating adverse effects of therapy. 18. Prescribe correct dosage, timing, and duration of therapy appropriate to the patient's total situation. (Clinical judgment) 19. Make therapeutic decisions in view of potential benefits, risks, and expected quality of life. 20. Take into account psychologic, environmental, and social factors in the formulation of therapeutic plans. 21. Develop management plans to prevent, minimize, or delay the development of known complications of the clinical conditions present. 22. Be able to make therapeutic decisions when necessary in the absence of a confirmed diagnosis. 23. Be able to improvise therapeutic plans in an emergency using available resources. 24. Be able to recognize those situations in which it is appropriate not to treat a medical problem or to treat it only symptomatically. 25. Be able to adapt therapeutic procedures to meet the special or changing needs of the medical situation. 26. Be able to recognize when a patient's illness has reached a point at which achieving an acceptable quality of life is unlikely, and at that time, be able to ensure that the patient dies with comfort and dignity.
biologic manifestations of the disease are unique. It is the illness of the patient that the internist must diagnose and treat (9). The discipline of internal medicine is defined by the scope of diseases and disorders cared for by the internist. Although the boundaries of medical content between internal medicine and other specialties overlap, internal medicine is unique in the breadth and depth of content that is encompassed by the well-trained internist. The scope of diseases within internal medicine can be described in a variety of ways. Standard textbooks of medicine provide a general description. In more specific terms, diseases can be classified by organ systems, etiology of disease, symptoms, and so on. Within these classifications, however, there is rarely any attempt to distinguish between diseases or disorders that are considered essential to the practice of the internist as contrasted with those about which the internist should have some, but not necessarily complete, knowledge. One approach is to categorize diseases into several levels of the abilities required of the internist (10). For one category (for example, essential hypertension), the internist should be able to carry out all phases of diagnosis and management
without consultation unless an uncommon or unusual manifestation of the disease may require the assistance of another specialist. For the next category level of diseases (for example, gluten enteropathy), the internist usually needs consultation at some point in managing a patient but would maintain primary responsibility and care for the patient. For diseases in the third category (for example, chronic renal failure requiring transplantation), the internist should have enough knowledge to be aware of and consider the presence of the disease but need not possess the necessary qualifications to maintain primary responsibility for the diagnosis and management of the illness. Another pertinent approach to the categorization of illnesses (6) uses the following criteria: [1] degree of preventability, [2] incidence or prevalence, [3] degree of treatability, [4] morbidity, and [5] mortality. THE PATIENT
The fourth variable in the medical encounter—the patient—is, of course, unique and therefore most difficult to categorize. Part of the challenge for the internist is to be sensitive to the individuality of the patient: To accommodate each patient, the internist must individualize the ABIM • Clinical Competence
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cy statements result in a comprehensive description of the internist's observable clinical behaviors. The statements set forth in Tables 3 through 9 have been developed from various sources such as the American Institute for Research Critical Incident Study (11), the American Board of Pediatrics' Foundations of Clinical Competence (6), and a critical incident study (12). The lists, augmented or edited by use, may serve several purposes. They can be used to identify measurable activities for the evaluation of students, residents, and internists. They may be useful to physicians by providing a more complete description of the desired standards of performance or to the public as a more explicit statement of the expectations of behavior or performance implied by certification and recertification. Conclusion
Figure 1 . Matrix of problem-solving tasks and problem-solving abilities.
clinical approach. For this reason, it is useful to suggest some of the general categories of patient factors that may alter or affect the clinical care rendered. The patient's personality will often profoundly affect the relationship with the internist and may require the highest level of interpersonal skills to achieve an optimal medical outcome. The patient's socioeconomic status will frequently require modification of the internist's approach. A patient's ethnic and cultural origin or religious preference can have an impact on the course of the medical illness: The patient's rights and preferences must be respected despite the fact that the internist may feel that to do so may threaten an optimal medical outcome. Patients' intellectual abilities and capacity for learning will differ greatly; yet, patient education is one of the most important factors in the resolution of the medical illness. The circumstances under which the patient is seen by the internist will also affect the nature of the encounter. When the patient has been referred for consultation by another physician, the internist is usually expected to focus on the problem for which the patient was referred. Although this focus is appropriate, the internist must still be thorough enough in the evaluation of the patient to identify all of the medical problems that exist. Awareness of these and other pertinent patient factors together with the abilities of the internist required to incorporate these factors into an appropriate management plan are essential to an optimal medical outcome.
The foregoing pages represent a distillation of the deliberations of the Board through several years. These deliberations have provided definitions and an analysis of the important components of the competencies expected of the internist. They have also resulted in the development of a multidimensional system (described in greater detail in the Board's unabridged version of this paper [14]), that it has found useful in evaluating its activities. As a result, the Board has clarified its functions and identified areas in which its activities should be improved. This paper is being published in the hope that it will be useful to other individuals and organizations in internal medicine. In workshops attended by representatives of these organizations, the following potential uses were suggested. 1. As a description of the components of clinical competence that internists should manifest. 2. In developing and evaluating educational programs. 3. As an aid to greater understanding by students and residents of the process of medical problem solving. 4. In the evaluation of the competency of residents. 5. As a means of identifying criteria for accreditation of training programs. 6. As criteria for the selection of medical students and residents. 7. As a definition of the internist for public agencies and the consumer. • Requests for reprints should be addressed to George D. Webster, M.D., Director of Evaluation; American Board of Internal Medicine; 3624 Science Center; Philadelphia, PA 19104. Received 17 November
Statements of Clinical Competence
Two of the four variables of the medical encounter discussed previously—problem-solving abilities and tasks—are always present regardless of the medical illness or patient involved. By focusing on the relation between these two variables as dimensions in a matrix (Figure 1), it is possible to organize statements that describe in detail the behaviors of the competent internist. If one pursues this approach to its fullest extent, the competen410
1978; revision accepted 8 January 1979.
References 1. C O U N C I L ON G E N E R A L I N T E R N A L M E D I C I N E , A M E R I C A N B O A R D O F
INTERNAL MEDICINE: Attributes of the general internist and recommendations for training. Ann Intern Med 86:472-474, 1977 2. A M E R I C A N B O A R D O F I N T E R N A L M E D I C I N E : Policies and
Procedures.
Philadelphia, American Board of Internal Medicine, 1978 3. FLEXNER A: Medical Education in the United States and Canada, Bulletin No. 4, The Carnegie Foundation for the Advancement of Teaching. Boston, Merry mount Press, 1910 4. ELSTEIN AS, SCHULMAN LS, SPRAFKA SA: Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, Massachusetts, Harvard University Press, 1978 5. KASSIRER JP, GORRY GA: Clinical problem solving: a behavioral analysis. Ann Intern Med 89:245-255, 1978
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6. A M E R I C A N B O A R D O F PEDIATRICS. Foundations
7. 8. 9. 10.
for Evaluating
Alto, California, American Institute for Research in the Behavioral Sciences, 1976
the
Competency of Pediatricians, Chicago, American Board of Pediatrics, Inc., 1974 REICHMAN S: Considerations for graduate training in internal medicine. JMedEduc 48:661-669, 1973 BLOOM BS (ed): Taxonomy of Educational Objectives: Cognitive Domain. New York, McKay, Co., Inc., 1956 BARONDESS JA: Disease and illness—A crucial distinction. Am J Med, in press for 1979 Hiss RG, VANSELOW NA: Objectives of a residency in internal medicine. Assoc Hosp Med Educ J 4:11 -52, 1971
12. P R I C E PB, T A Y L O R CW, N E L S O N DE, L E W I S EG, L A U G H M I L L E R GC, M A T H I E S E N R, M U R R A Y SL, M A X W E L L JS: Measurement and Predic-
tors of Physician Performance Two Decades of Intermittently Research. Salt Lake City, Utah, L. L. R. Press, 1971
Sustained
13. W O R K I N G G R O U P ON T H E T R A I N I N G A N D E V A L U A T I O N O F PHYSICIANS IN H I G H B L O O D PRESSURE: Education of physicians in high
blood pressure; performance characteristics, learning objectives and evaluation approaches. Circulation 51:pages 9-27, 1975 14. A M E R I C A N B O A R D O F I N T E R N A L M E D I C I N E : Clinical Competence
11. A M E R I C A N INSTITUTES FOR R E S E A R C H IN T H E B E H A V I O R A L SCI-
ENCES: The Definition of Clinical Competence in Internal Medicine; Performance Dimensions and Rationales for Clinical Skill Areas, Palo
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Internal Medicine. Philadelphia, American Board of Internal Medicine, in press for 1979
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entific and technologic successes of recent decades with the empathic care of the patient. Progress in technology may complicate the relationship between the patient and physician. Therefore the personal and caring relationship takes on even greater significance.
To describe more explicitly the components of competence required of the internist, The American Board of Internal Medicine has analyzed the medical encounter and defined the major variables involved: the abilities required of the internist, the tasks that must be performed to solve a medical problem, the medical illness, and the patient. The abilities of the internist have been categorized into attitudes and habits, interpersonal skills, motor and technical skills, and intellectual abilities. The latter have been further subdivided into the abilities to acquire and use knowledge, to organize, to synthesize information, and to apply clinical judgment. For each of these abilities statements of clinical competence that rebate to the tasks required have been developed. The Board is publishing this paper, an excerpt of a longer document, with the hope that it will be useful to residents, faculty, and practicing internists. [This article is an abridgment of a document with the same title that is being published concurrently by The American Board of Internal Medicine. Requests for copies of the unabridged document, "Clinical Competence in Internal Medicine," should be addressed to The American Board of Internal Medicine, 3624 Market Street, Philadelphia, PA, 19104, USA—The Editor] THE
AMERICAN
BOARD
OF
INTERNAL
MEDICINE
has
p r e v i o u s l y d e s c r i b e d (1) its c o n c e p t of t h e ideal i n t e r n i s t : A general internist is a physician who provides scientifically based, empathic care for the nonsurgical illnesses of adults. This care tends to be characterized by a mutual personal commitment between doctor and patient, by stability over time, by substantial breadth, by availability, and by an appropriate attention to elements of human support, sensitivity, and concern. It is marked by technical sophistication and major professional expertise. The general internist functions as a consultant to other specialists and is competent to handle critically ill patients and nonsurgical disorders in adolescents and adults seeking aid in the emergency room setting. Well-trained internists are unique in their ability to deliver with broad competence primary, secondary, and, in some instances, tertiary care. The general internist provides continuing, comprehensive care for common and complex multisystem illnesses in the ambulatory as well as the hospital setting. The internist serves as the patient's advocate and accepts responsibility for all the patient's health needs, obtaining assistance from other specialists and from allied health professionals as required. One of the hallmarks of the general internist is a continuing personal interest in the patient. The practice of internal medicine requires the knowledge and application of advances in the science and technology of medicine. The internist provides care that combines the sci• F r o m the American Board of Internal Medicine; Philadelphia, Pennsylvania. • T h i s document was prepared by the Board's Committee on Evaluation in General Internal Medicine: John A. Benson, Jr., M.D.; Alfred J. Bollet, M.D.; Saul J. Farber, M . D . (co-chairman); Daniel D. Federman, M . D . ; Wallace N . Jensen, M.D.; Lynn O. Langdon; William L. Morgan, M.D.; Donald E. Olson, M . D . (co-chairman); F r a n k A. Riddick, Jr., M.D.; and George D . Webster, M . D .
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To translate the qualities thus described into explicit components that will be useful in examining the process of certification and recertification, the Board established a Committee on Evaluation in General Internal Medicine charged with defining the knowledge, skills, and attitudes to be expected of the certifiable internist. The report of the committee, accepted by the Board in 1977, has been useful in several ways. It has served as a foundation for a more explicit statement by the Board of the goal of certification: "to provide assurance that the Diplomate possesses the knowledge, skills, and attitudes essential to the provision of excellent care in internal medicine" (2). It has helped in a reappraisal of the certification and recertification process. It has been used to evaluate and modify the Board's written examinations. It is now being used to modify the recommended procedures for evaluating candidates by training program directors. Because of the potential usefulness of the report in defining the practicing internist to organizations outside the Board, and after consultation with representatives of various organizations in or related to internal medicine, the committee's report has been revised to its present form as published here. Internal Medicine
Internal medicine is the major clinical science central to all the specialties of medicine and surgery that deal with the health and illness of adolescents and adults. In the mastery of this science, the internist must understand health and disease in relation to the totality of human behavior, physiology, and pathology. Internal medicine requires the constant correlation of clinical science with the basic and behavioral sciences. The internist should understand the life processes of normal cells, organs, and the human organism; the variability of these processes; and their abnormalities that lead to dysfunction and disease. New facts and concepts that emerge from research in the biologic and clinical sciences must be applied to the care of patients. This never-ending process is an integral part of the clinical competence of the internist. The cornerstones of the discipline of internal medicine and the other clinical sciences are the intellectual ability to conceptualize normal and abnormal biologic processes of the human body and the skills of clinical observation
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that lead to the ability to diagnose illness. The words of Flexner (3) regarding differential diagnoses and the construction of clinical hypotheses are as meaningful today as they were in 1910: The main intellectual tool of the investigator is the working hypothesis. The scientist is confronted by a definite situation, he observes it for the purpose of taking in all the facts. These suggest to him a line of action. He constructs an hypothesis. Upon this he acts, and the practical outcome of this procedure refutes, confirms or modifies his theory. Between theory and fact his mind flies like a shuttle; and theory is helpful and important just to the degree in which it enables him to understand, relate and control phenomena. This is essentially the technique of research: Wherein is it irrelevant to bedside practice? The physician too is confronted by a definite situation. He must seize its details, and only powers of observation trained in actual experimentation will enable him to do so. The patient's history, conditions, symptoms form his data. Thereupon, he too, frames his working hypothesis, now called a diagnosis. It suggests a line of action. Is he right or wrong? Has he actually amassed all the significant facts? Does his working hypothesis properly put them together? The sick man's progress is nature's comment and criticism. The professional competency of the physician is in proportion to his ability to heed the response which nature makes to his ministrations. The progress of science and the scientific and intelligent practice of medicine employ, therefore, exactly the same technique. Recent studies of the process of medical inquiry (4, 5) support Flexner's view. From the opening statement by the patient the physician begins a process of conceptual thinking that is often initially subconscious or automatic but leads to the formulation of hypotheses as to the nature of the problem. As data are accumulated and the hypotheses become better defined, efficient problem-solving habits lead to a reiterative, conscious matching of the information being elicited to information stored in the internist's memory. This matching process results in more directed data gathering designed to confirm or refute the hypotheses. For example, when a patient presents with generalized edema, likely initial hypotheses are that the problem is related to a disorder of the heart, the liver, or the kidney. An equally acceptable alternative set of hypotheses might be that the problem is either an expansion of extracellular volume or an abnormal distribution of extracellular volume. With these hypotheses, most internists begin the diagnostic process by predicting findings that would be expected and directing inquiries or physical examination or diagnostic procedures to check for the presence of the predicted findings; the resulting data support or refute the hypotheses or suggest new ones. This process continues until the medical problem is Table 1. Problem-Solving Abilities of the Internist Attitudes and habits Interpersonal skills Motor and technical skills Intellectual tools and abilities Knowledge Knowledge of pathophysiology Other medically related knowledge Organization Synthesis Clinical judgement
Table 2. Problem-Solving Tasks Data gathering History taking Physical examination Diagnostic study Diagnosis or problem definition Medical care Immediate Continuing resolved. After a diagnosis is reached, knowledge of the disease process must be integrated with knowledge of the patient and the environment to develop an optimal plan for treatment. As the results of therapy are observed, a need to acquire additional data, change the diagnostic hypothesis, or alter therapy may become apparent. The internist will constantly relate and integrate observed findings to knowledge learned previously through education or experience. This sequential hypothesis-testing approach to the diagnostic and therapeutic problem-solving process is more efficient than the accumulation of data without purpose, a process in which all of the data collected are reviewed at one time in the hope of recognizing a diagnostic pattern. The latter approach is highly prone to error, inefficient, and costly and lacks the conceptualization that is fundamental to understanding the illness of patients. The described sequential hypothesis-directed approach to problem solving should be highly developed in the internist. The internist's training should provide the environment and models to develop the necessary habits and abilities required. The evaluation of clinical competence should assess the degree to which the skill has been developed. Components of the Medical Encounter
In the hypothesis-directed approach to problem solving in a medical encounter, many different pathways or sequences could lead to equally acceptable solutions to the problem. However, some pathways or components are common to each encounter. Definition of these components and their interrelations allows the development of a system describing those functions of the practice of internal medicine that are the competencies to be taken into account in the education and evaluation of internists. This system is similar to that developed by The American Board of Pediatrics (6) and that described by Reichman (7). Each medical encounter contains at least four variables. I. The abilities the internist needs in resolving a medical problem: knowledge, skills, and attitudes. II. The tasks or functions that the internist must perform to resolve the medical problem: data gathering, problem definition, and therapy. III. The medical illnesses or health status of the patient: disease and factors important to health maintenance. IV. The patient; this variable includes not only a patient's physical response to disease process, but also facABIM • Clinical Competence
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Table 3. General Attitudes and Habits
The internist should 1. Have as his primary concern the welfare of his patients. 2. Provide comprehensive and continuing care to his patients using his and other sources of expertise as may be required to alleviate as much as possible all of his patient's health problems. 3. Be sensitive to the patient as a person and to his emotional, cultural, social, and physical needs. He must be able to accept the anxiety, fears, hostility, and anger that his patients may exhibit and accept responsibility for the patient's care without bias or prejudice. 4. Be accessible for his patients' needs and provide coverage by peers when he is unavailable. 5. Recognize his limitations and be willing to consult with other physicians when necessary, making appropriate use of their advice. He should not undertake management of a diagnostic or therapeutic procedure he is not qualified to do unless circumstances indicate that all alternatives carry greater risk. 6. Accept responsibility for educating patients or their families, or both, regarding problems, management plans, and decisions. 7. Use technologic restraint by avoiding diagnostic or therapeutic measures that are unnecessary or present undue risks. 8. Minimize the cost of medical care to the patient. 9. When acting as a consultant be appropriately thorough to identify medical problems other than those for which the patient was rpfprrpH 1 C1C11 C U .
10. When acting as a consultant, accept the responsibility for maintaining appropriate communication with the referring physician and support the referring physician-patient relationship unless the patient's welfare is jeopardized. 11. Participate in the continuing education of students, residents, peers, and other health personnel according to his ability. 12. Participate according to his talents in the solution of health care problems in the community and society. 13. Devote the interest, time, and energy required to maintain and upgrade his clinical knowledge and skills. 14. Understand the limitations of current medical knowledge in explaining all aspects of a patient's problems. tors such as personality, socioeconomic status, and cultural, family or other environmental factors. Although many patient variables are of a scope and complexity that preclude their analysis in this document, this variable is important because the patient frequently affects the function of the internist and the outcome of the medical encounter. PROBLEM-SOLVING ABILITIES
The abilities of the internist are those needed to use the hypothesis-directed process described. Although it is difficult to identify all the discrete abilities required for the complex process of a medical encounter, they can be helpfully categorized into four major components (Table 1): attitudes and habits, interpersonal skills, motor and technical skills, and intellectual abilities. The intellectual abilities can be further subdivided into a hierarchy like that of the cognitive levels described by Bloom and associates (8). These abilities are complex and often overlapping. For any particular task several or all levels of abilities might be involved. For example, in evaluating a patient with an unknown type of liver disease, the internist may decide that a liver biopsy is indicated after considering knowledge of the indications and possible complications of the procedure. Interpersonal skills may be important in gaining the patient's cooperation and motor skills are needed
to obtain a satisfactory specimen with the least danger and discomfort to the patient. Finally the biopsy findings are organized with other knowledge of the patient's illness and synthesized to reach a diagnostic or management decision. Attitudes and Habits: The standards of behavior to which the internist should be committed in clinical practice. Some of the desirable attitudes and habits to which an internist should be committed in practice are not held solely by the profession but, rather, are those valued by all of society. Further, any of the specific attitudes or habits referred to in this document are not unique to the internist, but because of their importance to the internist, they deserve emphasis here. These attitudes and habits have been set forth within the initially stated description of the internist, and they are stated in behavioral terms in the section, "Statements of Clinical Competence." In addition to integrity and ethical behavior, they can be summarized as four qualities: willingness to take responsibility for the whole care of the patient; comprehensiveness and thoroughness in care; empathy for the patient that helps to alleviate discomfort and anxiety; and scholarship that maintains the intellectual skills needed for clinical competence. Interpersonal Skills: The communication abilities, verbal and nonverbal, required of the internist to interact
Table 4. General Interpersonal Skills
The internist should have the interpersonal skills to 1. Develop a strong relationship that inspires confidence in patients and conveys a feeling of interest and concern. 2. Communicate to patients and patients' families information about diagnosis, prognosis, and management. 3. Interact in a nonjudgmental manner. 4. Be alert to and interpret nonverbal clues from the patient. 5. Recognize and be attentive to the patients' emotional needs and recognize their potential influence on the symptoms and course of the ill
rtacc
6. Educate the patient in health maintenance. 7. Communicate with and inspire cooperation with other members of the health care team. 8. Communicate effectively and tactfully with colleagues both as a consultant and as a member of the health care team. 404
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Table 5. Competence in History Taking
In obta;ining a medical history from a patient, the internist should (Attitudes and habits) 1. Develop the habit of completing and recording a complete history. 2. Be sensitive to symptoms or statements which suggest depression or psychosomatic illness. 3. Develop the habit of updating and supplementing historical data on follow-up visits. 4. Pursue with appropriate thoroughness all historical clues. (Interpersonal skills) 5. Be able to establish rapport with the patient and other informants that makes possible the obtaining of a complete and accurate history. 6. Be able to recognize verbal and nonverbal clues from the patient and pursue the indicated lines of inquiry. 7. Be able to adapt language appropriately to ensure communication with persons of differing ethnic, cultural, or nationality backgrounds. 8. Be able to adapt to patients who present a disjointed or disorganized history. (Motor and technical skills) 9. Be able to use techniques, such as body posture and eye contact, that facilitate communication. (Knowledge) 10. Have depth of knowledge that allows a thorough exploration of symptoms relating to the patient's problem. 11. Have depth of knowledge that allows consideration of various etiologies to explain the patient's symptoms. (Pathophysiology) 12. Understand symptoms in terms of altered structure and function of body systems. 13. Differentiate between symptoms that arise directly from a disease process and those that occur as a result of the body's response to disturbed homeostasis. (Organization) 14. Approach the history in a logical, directed way to ensure completeness. 15. Follow-up medical clues in a directed, logical pattern. 16. Organize and record the history completely in a fashion that will be understandable to all potential users of the record. (Synthesis) 17. While obtaining history, integrate symptoms into diagnostic hypotheses. 18. Recognize symptom patterns that suggest even low-frequency diseases. 19. As additional data are obtained, be able to formulate new or additional diagnostic hypotheses. (Clinical judgment) 20. Assess the reliability of the history obtained. 21. Separate appropriately irrelevant from relevant information. 22. Identify information that seems incongruous with the clinical situation.
effectively with other persons during the practice of medicine. The people with whom the internist must be able to communicate include the patient, patient's family, and other physicians and members of the allied health team. Skills in interpersonal relations are important to provide understanding, establish an appropriate patient-physician relationship, give the patient confidence, and provide effective care continuously. These communication or interpersonal skills include the ability to elicit accurate information and evaluate its reliability, communicate factual information clearly, and know how to respond to nonverbal communication. Such skills include the ability to recognize the individuality of each patient and the uniqueness of each situation. Different skills may be needed when the internist is functioning as a consultant rather than as a primary physician. Motor and Technical Skills: The learned manual or psychomotor skills necessary to perform physical examinations and other diagnostic and therapeutic procedures. The most basic of these skills are those needed to do a directed yet comprehensive physical examination. This skill is essential for all internists. Although possession of this skill has been assumed by some training-program faculty and evaluators, competence in this area is often lacking. Although some deficits are the result of the lack of appropriate habits, many are the result of the failure to develop sufficient motor or sensory skills to elicit or
detect subtle findings. Other motor skills are needed to perform various procedures. These range from the basic procedures such as venipuncture, lumbar puncture, and thoracentesis to more complex procedures such as liver or kidney biopsy, insertion of intravascular catheters for monitoring, pericardiocentesis, and peritoneal dialysis. The technical procedures the internist performs will be determined by the kind of practice, personal preferences, local custom, the availability of other skilled professionals, and local delineation of privileges. Each physician has to take responsibility for developing proficiency in those procedures performed. Intellectual Tools and Abilities: A variety of intellectual abilities are required for the internist to proceed through the reiterative problem-solving sequence. The intellectual processes used to solve medical problems is much more complex than implied by a list of five intellectual abilities. Identification of some intellectual abilities can, however, be a useful aid in understanding the process used in medical problem solving. In general, the intellectual abilities of clinical judgement and synthesis are more complex than knowledge and organization; however, the abilities are neither unique nor unrelated, and they overlap to a large extent. Knowledge: The store of information or facts pertinent to particular diseases or illnesses and the ability of the internist to apply that information in the clinical setting. ABIM • Clinical Competence
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Table 6. Competence in Physical Examination
In doing a physical examination the internist should (Attitudes and habits) 1. Develop the habit of doing a complete physical examination unless inappropriate to the clinical situation. 2. Pursue appropriately all abnormal physical findings. (Interpersonal skills) 3. Be able to encourage the patient's cooperation so that a complete physical examination is possible. 4. Undertake the physical examination with concern for the patient's comfort, privacy, and sensitivity, forewarning the patient of uncomfortable or unanticipated maneuvers. (Motor and technical skills) 5. Be able to elicit subtle as well as obvious physical findings by inspection, percussion, palpation, or ausculation and be able to use appropriate instruments such as the ophthalmoscope, tonometer, and sigmoidoscope. 6. Be able to modify physical examination procedures to adapt to particular medical situations. (Knowledge) 7. Know the range of normal variation of physical findings. 8. Know alternative techniques capable of confirming abnormal findings. (Pathophysiology) 9. Have a knowledge of anatomic relations. 10. Have knowledge of the physical or physiologic mechanisms that produce normal and abnormal physical findings. 11. Understand and use physiologic maneuvers that can elicit findings that would otherwise not be apparent. (Organization) 12. Proceed through the physical examination in an orderly fashion to ensure completeness. 13. Record the physical examination systematically so that it will be understandable to all potential users of the record. (Synthesis) 14. Integrate physical findings, normal or abnormal, with the diagnostic hypotheses suggested by history or other data. 15. Recognize patterns of findings that confirm diagnostic impressions or suggest new diagnostic possibilities. (Clinical judgment) 16. Be able to judge the significance of borderline abnormal findings. 17. In the presence of multiple diseases, assign findings to the appropriate disease process. 18. Be able to judge how often and to what extent a physical examination should be repeated on a given patient. This category includes the general information, or set of facts and relationships, an internist learns from formal education, textbooks, journals, and clinical experience. These facts may be easily recalled by memory or they may be stored in a variety of resources and retrieved by reference. The internist needs to kow facts of various kinds. In addition to empiric knowledge of diseases, knowledge is required of epidemiology, psychology, sociology, and so on. Central to this body of knowledge is knowledge of the basic medical sciences as they relate to disease. Because of the importance of this subset of knowledge, it is emphasized in this document by giving it a separate heading, "Pathophysiology.' * Pathophysiology: The knowledge of the medically related basic sciences. This category includes knowledge of the normal state as well as knowledge of the way in which biologic systems are altered by disease. Knowledge of pathophysiology can be retained in the internist's memory or retrieved from reference sources. The importance of this category derives from the conviction that the internist, in order to have complete understanding of the significance of clinical findings, should relate them to basic principles of altered structure and function. This full knowledge and understanding makes possible medical decisions that are most relevant, and prognoses that are most accurate, and allows detection of unexpected or aberrant findings. This knowledge provides direction and meaning to clinical decisions. Organization: The ability to systematize clinical data and related knowledge in a medically logical, directed, and purposeful manner. 406
The ability to organize is the capacity to combine findings so that their sequence and relation are evident. Manifestations of this ability include the presentation of a concise oral or written summary of pertinent data, the development of a logical and sequential diagnostic and therapeutic plan, and the development and maintenance of interpretable records over time. Synthesis: The process of combining all of the relevant pieces of information and constructing from them an integrated concept. After pertinent clinical data have been arranged into an ordered pattern, clinical problem solving requires a synthesis of these data to make sets of findings meaningful. Synthesis is the essence of diagnosis or problem definition. Although synthesis has many levels and components, there are two that are useful to distinguish: pattern recognition and integration. Pattern recognition is identification of a set of related components that is recognized as a previously learned entity. Integration is a combination of complex data in such a way as to apply several concepts or principles to reach a conclusion that was not initially apparent. Although the distinction between these two may be easy in many circumstances, in others it is difficult. An internist may be required to integrate complex data when a problem is presented the first time; however, with the experience of observing similar data repeatedly, part of the process of synthesis becomes one of pattern recognition. Clinical Judgment: The ability to make clinical decisions based on the assignment of appropriate values to a set of facts or to a synthesis of a set of facts. This category represents the ability of the physician to
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Table 7. Competence in Diagnostic Study
In ordering or performing diagnostic procedures the internist should (Attitudes and habits) 1. Use the laboratory mainly to confirm or refute diagnostic hypotheses. 2. Accept responsibility for using most effective and least risky procedures that minimize cost of health care. 3. Be able to accept responsibility for ordering potentially risky or costly procedures that are essential for the solution of a patient's problem. (Interpersonal skills) 4. Be able to explain to patients the purpose, possible complications, and factors necessary to make the procedures comfortable, safe, and interpretable. (Motor and technical skills) 5. Be technically proficient in the performance of those procedures undertaken. (Knowledge) 6. Know the range of biologic variation in test results. 7. Know the indicated procedures including special or unusual studies. 8. Know the diagnostic specificity and limitations of laboratory studies. 9. Know how to perform or order test procedures in a manner most likely to ensure interpretable results. 10. Recognize invalid test results. (Pathophysiology) 11 Understand the underlying rationale of the indicated procedures. 12. Interpret the results of procedures in terms of alterations in underlying pathophysiology. 13. Recognize laboratory results that reflect homeostatic responses to disease in contrast to those that reflect the effect of disease. (Organization) 14. Order laboratory studies in a logical sequence to avoid unnecessary procedures or costs and observe appropriate timing of procedures to avoid invalidating test results. 15. Record laboratory findings in a logical, organized fashion. (Synthesis) 16. Accurately interpret test results. 17. Recognize patterns of diagnostic information. 18. Integrate data appropriately to confirm or refute diagnostic hypotheses. (Clinical judgment) 19. Select from alternatives those diagnostic procedures with the greatest likelihood of useful results, taking into account risk and cost. 20. Make appropriate judgments from conflicting laboratory results. 21. Adapt diagnostic procedures to meet the special requirements of the medical situation. 22. Discern when indicated procedures should be delayed, as in an emergency. 23. Judge the validity and reliability of laboratory studies in each clinical situation. choose selectively and wisely among alternative diagnostic and therapeutic possibilities. The internist does this by evaluating these possibilities as they relate to a particular clinical situation. Examples of clinical judgments include determining the appropriate balance of risk and benefit of alternative courses of action or inaction, making value judgments in each situation with respect to the need for thoroughness as contrasted to efficiency, and establishing priorities for the allotment of resources. It also includes the evaluation of facts or theories that appear in the medical literature. In each of these examples the internist, drawing from a variety of information and experience, must weigh pertinent factors and make a conscious decision. PROBLEM-SOLVING TASKS
The elements or events within the complex process that occurs in a clinical encounter are difficult to describe and arrange systematically because differences of style, perspective, or experience may result in an infinite variety of sequences that lead to the same solution and are equally acceptable. However, there are common elements or tasks in the process that can be identified. These tasks need not be done in a particular sequence; the sequence of tasks will differ with the person doing them and the medical problem being evaluated. The categories of tasks that describe the problem-solv-
ing process are described in Table 2. Implied in each of these categories is not only the overt activity involved (for example, interviewing the patient, doing a physical examination, ordering laboratory tests) but also the internist's understanding and interpreting of the information relating to the patient's illnesses. History Taking: The acquisition of a chronologic, medically logical description of pertinent events in the present illness, the past medical history, family history, and social history; the review of systems; the review of patient medical records; the acquisition of in formation obtained from the family and other sources and information available from other written and nonverbal communications. Included in this task is the correlating of the internist's knowledge of those disease(s) suggested by the patient's symptoms with information concerning the patient. This correlation and integration of knowledge with facts are needed to create a directed, logical history. Physical Examination: The elicitation of findings from an appropriately thorough examination of the patient that documents the presence or absence of signs or abnormalities that are relevant to the pertinent health problems of the patient. The patient's physical findings must be correlated with those expected or unexpected in the hypothesized disease(s). Diagnostic Study: The appropriate selection and accurate interpretation of laboratory or other diagnostic proABIM • Clinical Competence
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Table 8. Competence in Diagnosis or Problem Definition
In reaching decisions about patients and their medical problems, the internist should (Attitudes and habits) 1. Develop the habit of relating as much as possible the clinical situation of a patient to the total body of knowledge and experience in medicine. 2. Consider explanations for all of the clinical findings obtained. 3. Develop the habit of considering psychologic disease as a possible explanation of a patient's symptoms. 4. Strive for the most definitive diagnosis for each problem. 5. Carefully consider diagnostic possibilities suggested by patients or other sources of information. (Interpersonal skills) 6. Be able to express clearly to patients and families facts about the diagnosis that will ensure their understanding and cooperation. (Mot(or and technical skills) 7. Not applicable. (Knowledge) 8. Consider all the diagnostic possibilities that might explain the data obtained. 9. Possess knowledge of the manifestations of the likely causes of the patient's disease. 10. Be able to link the clinical findings to knowledge of the natural history of disease such as epidemiology, course, complications, and prognosis. (Pathophysiology) 11. Express diagnoses in terms of altered structure and function where appropriate. 12. Be able to explain in pathophysiologic terms the relation between the diagnosis and the presence or absence of symptoms, signs, or findings. 13. Be able to apply established and emerging concepts in the basic medical sciences to clinical problem solving. (Organization) 14. Obtain and record data including appropriate negative information, knowledge of which is indicated by the nature of the disease present. 15. Record diagnoses in a logical fashion in the medical record. 16. Discuss the patient's diagnoses and problems in progress notes in an organized and complete fashion. 17. Record all appropriate diagnoses and problems in the medical record to ensure adequate follow-up. 18. Be able to present a patient's problems to consultants or other personnel in an organized, logical fashion. (Synthesis) 19. Use knowledge of disease processes to integrate data obtained into diagnostic hypotheses. 20. Recognize clusters of signs and symptoms associated with particular disease entities. 21. Use all data in making final diagnostic decisions. 22. Recognize unusual or aberrant findings as they relate to the diseases under consideration. 23. Recognize low-probability diagnoses suggested by the findings. 24. Recognize manifestations of psychologic disturbances. 25. Be able to diagnose the presence of multiple or complex interacting disorders. (Clinical judgment) 26. Develop final diagnostic formulations by evaluating all available data and information. 27. Be able to make diagnostic decisions when necessary in the absence of complete data. 28. Use available data from the literature or other sources as an aid to assessing the importance of conflicting findings. 29. Be able to revise or suspend judgements when acute new complications or findings of illness occur. cedures that are indicated from the internist's knowledge of the patient and the suspected condition(s). Diagnosis or Problem Definition: The decision regarding the diagnosis(es) or differential diagnosis that is specific enough to permit the formulation of a management plan. In the data-gathering process, the internist will develop a number of diagnostic hypotheses, based on a store of knowledge concerning the natural history of the diseases under consideration (etiology, epidemiology, prognostic probabilities, and so on) and other facts known about the patient. Some of these hypotheses will be rejected as a result of directed data gathering. At some point, the internist will integrate all of the available information and make a decision or decisions directed toward management of the illness. One can collect data exhaustively; a competent internist knows when to formulate a diagnosis and implement a plan of management. Medical Care: The preventive or therapeutic activities that are designed to maintain health and modify, alleviate, or resolve the patient's problems, including those of a personal or emotional nature. A decision not to treat may be an appropriate management plan. For this document, 408
management has been subdivided into two categories, immediate care and continuing care, to emphasize some of the activities included in the latter category. Immediate Care: Emergency or acute medical care. Immediate care is arbitrarily defined as that initiated promptly or within the first few days or weeks of a patient's problem; the need for care is expected to be of limited duration. Continuing Care: Prolonged care through weeks, months, or years dictated by the nature of the patient's problem. Continuing care is expected to be of long duration but may have to be started immediately. Included are the activities associated with maintenance of health or preventive medicine, patient and family education, measures directed toward the risk factors of disease, modifications of life style or environment where indicated, anticipation of complications, and appropriate followup of the patient with re-evaluation of health problems. T H E MEDICAL ILLNESS
The term illness is used, rather than disease, to emphasize the fact that when a disease occurs in a person the
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Table 9. Competence in Medical Care: Immediate and Continuing
In prescribing medical care, the internist should (Attitudes and habits) 1. Provide comprehensive and continuing care to his patients whenever appropriate, taking into account pertinent socioeconomic factors. 2. Accept the responsibility to see that all sources of expertise are used to ensure the best outcome of all the patient's health problems. 3. Refer to others the management of patients requiring technical therapeutic procedures that the internist may not be qualified to perform. 4. Resist patient demands for inappropriate therapy. (Interpersonal skills) 5. Be able to educate patients and families adequately to ensure compliance with immediate and continuing management plans. (Motor and technical skills) 6. Be proficient in those therapeutic procedures requiring technical skills. (Knowledge) 7. Know the most effective therapies available for the problems. 8. Know the correct procedures for instituting the indicated therapy. (Pathophysiology) 9. Have knowledge of interactions between drugs and the need to modify drug therapy in the presence of specific organ dysfunction. 10. Understand the mechanisms of drug action and the acute and chronic side-effects. (Organization) 11. Document thoroughly all therapeutic plans. 12. Organize available resources to ensure patient compliance, including patient education. 13. Establish monitoring procedures to assess patient compliance and the results of therapy. 14. Inform and instruct all health professionals involved in the care of the patient of the details of the therapeutic plans. 15. Arrange for long-term follow-up and care, including rehabilitation. (Synthesis) 16. Devise a therapeutic plan that considers all the patient's active, treatable problems. 17. Recognize signs and symptoms indicating adverse effects of therapy. 18. Prescribe correct dosage, timing, and duration of therapy appropriate to the patient's total situation. (Clinical judgment) 19. Make therapeutic decisions in view of potential benefits, risks, and expected quality of life. 20. Take into account psychologic, environmental, and social factors in the formulation of therapeutic plans. 21. Develop management plans to prevent, minimize, or delay the development of known complications of the clinical conditions present. 22. Be able to make therapeutic decisions when necessary in the absence of a confirmed diagnosis. 23. Be able to improvise therapeutic plans in an emergency using available resources. 24. Be able to recognize those situations in which it is appropriate not to treat a medical problem or to treat it only symptomatically. 25. Be able to adapt therapeutic procedures to meet the special or changing needs of the medical situation. 26. Be able to recognize when a patient's illness has reached a point at which achieving an acceptable quality of life is unlikely, and at that time, be able to ensure that the patient dies with comfort and dignity.
biologic manifestations of the disease are unique. It is the illness of the patient that the internist must diagnose and treat (9). The discipline of internal medicine is defined by the scope of diseases and disorders cared for by the internist. Although the boundaries of medical content between internal medicine and other specialties overlap, internal medicine is unique in the breadth and depth of content that is encompassed by the well-trained internist. The scope of diseases within internal medicine can be described in a variety of ways. Standard textbooks of medicine provide a general description. In more specific terms, diseases can be classified by organ systems, etiology of disease, symptoms, and so on. Within these classifications, however, there is rarely any attempt to distinguish between diseases or disorders that are considered essential to the practice of the internist as contrasted with those about which the internist should have some, but not necessarily complete, knowledge. One approach is to categorize diseases into several levels of the abilities required of the internist (10). For one category (for example, essential hypertension), the internist should be able to carry out all phases of diagnosis and management
without consultation unless an uncommon or unusual manifestation of the disease may require the assistance of another specialist. For the next category level of diseases (for example, gluten enteropathy), the internist usually needs consultation at some point in managing a patient but would maintain primary responsibility and care for the patient. For diseases in the third category (for example, chronic renal failure requiring transplantation), the internist should have enough knowledge to be aware of and consider the presence of the disease but need not possess the necessary qualifications to maintain primary responsibility for the diagnosis and management of the illness. Another pertinent approach to the categorization of illnesses (6) uses the following criteria: [1] degree of preventability, [2] incidence or prevalence, [3] degree of treatability, [4] morbidity, and [5] mortality. THE PATIENT
The fourth variable in the medical encounter—the patient—is, of course, unique and therefore most difficult to categorize. Part of the challenge for the internist is to be sensitive to the individuality of the patient: To accommodate each patient, the internist must individualize the ABIM • Clinical Competence
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cy statements result in a comprehensive description of the internist's observable clinical behaviors. The statements set forth in Tables 3 through 9 have been developed from various sources such as the American Institute for Research Critical Incident Study (11), the American Board of Pediatrics' Foundations of Clinical Competence (6), and a critical incident study (12). The lists, augmented or edited by use, may serve several purposes. They can be used to identify measurable activities for the evaluation of students, residents, and internists. They may be useful to physicians by providing a more complete description of the desired standards of performance or to the public as a more explicit statement of the expectations of behavior or performance implied by certification and recertification. Conclusion
Figure 1 . Matrix of problem-solving tasks and problem-solving abilities.
clinical approach. For this reason, it is useful to suggest some of the general categories of patient factors that may alter or affect the clinical care rendered. The patient's personality will often profoundly affect the relationship with the internist and may require the highest level of interpersonal skills to achieve an optimal medical outcome. The patient's socioeconomic status will frequently require modification of the internist's approach. A patient's ethnic and cultural origin or religious preference can have an impact on the course of the medical illness: The patient's rights and preferences must be respected despite the fact that the internist may feel that to do so may threaten an optimal medical outcome. Patients' intellectual abilities and capacity for learning will differ greatly; yet, patient education is one of the most important factors in the resolution of the medical illness. The circumstances under which the patient is seen by the internist will also affect the nature of the encounter. When the patient has been referred for consultation by another physician, the internist is usually expected to focus on the problem for which the patient was referred. Although this focus is appropriate, the internist must still be thorough enough in the evaluation of the patient to identify all of the medical problems that exist. Awareness of these and other pertinent patient factors together with the abilities of the internist required to incorporate these factors into an appropriate management plan are essential to an optimal medical outcome.
The foregoing pages represent a distillation of the deliberations of the Board through several years. These deliberations have provided definitions and an analysis of the important components of the competencies expected of the internist. They have also resulted in the development of a multidimensional system (described in greater detail in the Board's unabridged version of this paper [14]), that it has found useful in evaluating its activities. As a result, the Board has clarified its functions and identified areas in which its activities should be improved. This paper is being published in the hope that it will be useful to other individuals and organizations in internal medicine. In workshops attended by representatives of these organizations, the following potential uses were suggested. 1. As a description of the components of clinical competence that internists should manifest. 2. In developing and evaluating educational programs. 3. As an aid to greater understanding by students and residents of the process of medical problem solving. 4. In the evaluation of the competency of residents. 5. As a means of identifying criteria for accreditation of training programs. 6. As criteria for the selection of medical students and residents. 7. As a definition of the internist for public agencies and the consumer. • Requests for reprints should be addressed to George D. Webster, M.D., Director of Evaluation; American Board of Internal Medicine; 3624 Science Center; Philadelphia, PA 19104. Received 17 November
Statements of Clinical Competence
Two of the four variables of the medical encounter discussed previously—problem-solving abilities and tasks—are always present regardless of the medical illness or patient involved. By focusing on the relation between these two variables as dimensions in a matrix (Figure 1), it is possible to organize statements that describe in detail the behaviors of the competent internist. If one pursues this approach to its fullest extent, the competen410
1978; revision accepted 8 January 1979.
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INTERNAL MEDICINE: Attributes of the general internist and recommendations for training. Ann Intern Med 86:472-474, 1977 2. A M E R I C A N B O A R D O F I N T E R N A L M E D I C I N E : Policies and
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blood pressure; performance characteristics, learning objectives and evaluation approaches. Circulation 51:pages 9-27, 1975 14. A M E R I C A N B O A R D O F I N T E R N A L M E D I C I N E : Clinical Competence
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