Reinventing specialty training of physicians? Principles and challenges
¿Reinventar la formación de médicos especialistas? Principios y retos
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Principles and challenges" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "604" "paginaFinal" => "612" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => " Miembros de la Junta Directiva de la Sociedad de Educación Médica de Euskadi. www.ehu.es/SEMDE, Jesús Morán-Barrios, Pilar Ruiz de Gauna Bahillo" "autores" => array:3 [ 0 => array:1 [ "apellidos" => "Miembros de la Junta Directiva de la Sociedad de Educación Médica de Euskadi. www.ehu.es/SEMDE" ] 1 => array:4 [ "nombre" => "Jesús" "apellidos" => "Morán-Barrios" "email" => array:1 [ 0 => "jesusmanuel.moranbarrios@osakidetza.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Pilar" "apellidos" => "Ruiz de Gauna Bahillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Docencia Médica, Hospital de Cruces. Osakidetza-Servicio Vasco de Salud, Baracaldo, Vizcaya, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 1 => array:3 [ "entidad" => "Departamento de Teoría e Historia de la Educación, Universidad del País Vasco-Euskal Herriko Unibertsitatea, San Sebastián-Donostia, Guipuzkoa, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Reinventar la formación de médicos especialistas? Principios y retos" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">TRAINING OF PHYSICIANS IN AND FOR A HUMANISED AND FAIRER GLOBALISED WORLD</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Can we and should we continue training our residents with the same professional profile of as little as three years ago? What new skills must we introduce and work with in training to make future professionals more responsible and capable of managing universal and growing healthcare demands, with limited resources; professionals who have to continue acquiring knowledge (both scientific and technical) in a globalised world, full of uncertainty that should be moving towards greater equality?</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">We live in a delicate, historic time due to the major changes that society has experienced in recent years. Our lives revolve around problems occurring elsewhere on the planet, distant each from each other and thousands of kilometres from us. Just three years ago we were far less conscious of the impact that the decisions of others could have on our lives, with consequences (the current economic crisis) that are significant for our society and that will permanently affect the political, sociocultural, and moral environment of all societies. We are seeing the other side of the coin of globalisation; a phenomenon of economic interdependence that has been intensely experienced since the 1990s and that has resulted in the neoliberal politics we see today. Globalisation is taking place in the financial sector, but also effects politics, science, culture, education and healthcare<span class="elsevierStyleSup">1</span>.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">In terms of the training of healthcare professionals of any kind we should ask ourselves: For what (world) and for whom (people) are we doing this training? The direction that training institutions (universities, educational centres, and health centres/hospitals) should take is based on the need to humanise society<span class="elsevierStyleSup">2</span>. In this respect, a goal of the process of training professionals must be to encourage a consciousness of universal citizenship, which will facilitate the process of change towards a new understanding of citizenship. Some time ago, organisations such as the World Health Organisation (WHO) recommended that, within the teaching environment and the practice of medicine, measures must be taken to provide education aiming to achieve equitable, efficient and comprehensive care for patients, families and communities, according to the needs and values of their society.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Medical training must undergo certain changes if it is to contribute to the amelioration of some of the deficits resulting from globalisation. The commitment of training institutions must be to enable the training of professionals by and for the community, teaching them about community values of solidarity and empathy, and to be able to put themselves in the shoes of others. This commitment must not be on paper alone, but should manifest itself through training programmes and the actions of teachers. This commitment should focus on training that strengthens, among other aspects, the bonds between different cultures, life-long learning, autonomy and personal and professional responsibility, a universal vision, and, lastly, caring, creative and critical thinking<span class="elsevierStyleSup">1</span>. Training based around competencies and their evaluation allows us to tackle these challenges and commitments.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE EUROPEAN AREA AND MEDICAL TRAINING IN</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">A CHANGING SOCIETY</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Medical training in Spain is facing new challenges resulting from an important change in the educational scene in Europe: the European Higher Education Area (Bologna Declaration of 1999<span class="elsevierStyleSup">3</span>). A process of convergence has begun that has as its aim to facilitate the mobility of graduates and adapt the content of university studies to social demands. It is an attempt to create a Europe of knowledge (a <span class="elsevierStyleItalic">knowledge society</span>, an expression coined by Peter Drucker in 1969<span class="elsevierStyleSup">4</span>, not linked to the quantity of knowledge but rather to its productivity, that is, its economic impact). The Bologna Declaration states that «A Europe of Knowledge is now widely recognised as an irreplaceable factor for social and human growth and as an indispensable component to consolidate and enrich the European citizenship, capable of giving its citizens the necessary competencies to face the challenges of the new millennium, together with an awareness of shared values and belonging to a common social and cultural space».<span class="elsevierStyleSup">3 </span> This does not just involve the mobility students, but also of professionals with the consequent recognition of qualifications, which implies a profound change in medical training models both at the university level as well as in specialty training. In addition, continuously changing social needs require dynamic health systems that must offer safe, effective, efficient, and high quality responses to the needs and expectations of citizens<span class="elsevierStyleSup">5</span>.<span class="elsevierStyleSup"> </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The competency profile for health professionals should take into account the need for this responsiveness. Specifically, the profile must continuously be adapted and developed with new competencies, which in turn lead to modifications in learning and evaluation systems. This is important to guarantee, in the case of physicians, a good doctor-patient relationship in which there is a direct influence of  demographic, epidemiological, financial, legal, and scientific-technical changes, cultural aspects, ethics and values, and new models of organisation and healthcare management (clinical management), as well as of the media and the culture of consumption<span class="elsevierStyleSup">6</span>.<span class="elsevierStyleSup"> </span>Regarding these changes, A. Jovell and M. Navarro<span class="elsevierStyleSup">7</span> highlight three social phenomena: changes in the labour structure of health professions, the appearance of a new patient/citizen model, and the transformation and increase in the complexity of knowledge management. To that, we must add the collectivisation of the provision of health services as a strategy to guarantee equitable access. The challenge for today’s physicians is to know how to respond effectively and efficiently to the needs of the 21<span class="elsevierStyleSup">st</span> century and to the confidence placed in them by patients<span class="elsevierStyleSup">5</span>.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Therefore, “the simple idea that a competent professional is one who possesses the knowledge and abilities that can lead to success in a specific profession is out of date. This idea has been replaced by the understanding that professional competency is a complex phenomenon which expresses the potential of individuals to direct their actions in the exercise of their profession with initiative, flexibility and autonomy, in diverse scenarios, based on the integration of knowledge, skills, motives and values, and is demonstrated by efficient, ethical, and socially committed professional work. It is necessary to eliminate fear of the unknown and join in the adventure of change from within; innovate and comprehend the new reality; and face up to the future and understand our role in this reality» (Pilar Martínez Clarés)<span class="elsevierStyleItalic">. </span>Today’s training of tomorrow’s specialists means providing the competencies necessary to confront the uncertainties of future clinical practice, and appropriately manage future changes in society and within the medical profession itself (the areas of specialisation and collaboration between them, for example), as well as identifying and understanding the role of the physician among the various stakeholders that influence the profession of medicine (the state/governments, health organisations/corporations, the health technology and pharmaceutical industry, citizens and other health professionals<span class="elsevierStyleSup">8,9</span>).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">It is within this context of ever greater and more complex transformations that competency-based training (CBT) emerges to enable the better adaptation and development of individuals<span class="elsevierStyleSup">10</span>, in this case, physicians. CBT focuses on learning and not on teaching, and on reaching specific objectives, i.e., on the results of learning, integrating knowledge and knowing how to do, be and act<span class="elsevierStyleSup">11</span>.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE RESIDENCY SYSTEM (SPECIALISED HEALTH TRAINING), NEW CHALLENGES AND OPPORTUNITIES</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Training medical specialists involves the gradual integration of recent graduates in medicine into the care activities of a health centre or hospital with growing responsibility and decreasing supervision over time. Is it possible to carry out this professional training without having the tools and resources necessary to guarantee that this integration is appropriately planned and supervised, and that the final result (a competent medical specialist) is the consequence of completing a programme designed to meet current healthcare demands?<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The Spanish system for medical graduate training, known as the MIR, was born in the 1960s as a result of the “<span class="elsevierStyleItalic">Seminario de Hospitales</span>” (a meeting bringing together representatives of major hospitals from across Spain: Hospital de la Santa Creu i Sant Pau, Clínica Puerta de Hierro, Hospital Marqués de Valdecilla, Fundación Jiménez Díaz, Hospital de Basurto, and Hospital General de Asturias )<span class="elsevierStyleSup">13</span>. It is based on learning on-the-job and has been one of the most important drivers of the modernisation of medical practice in Spain. The system, as regulated in 1984, has a strong state structure controlled from the Spanish Ministry of Health and Social Policy<span class="elsevierStyleSup">14</span>. The following characteristics of the system should be highlighted: the accreditation of healthcare centres and teaching units (clinical departments), whose guarantee of quality training is monitored through regular audits; a universal entrance exam; and the definition and classification of specialties and associated programmes, as regulated by the corresponding National Specialty Commissions and a National Council. However, there are considerable weaknesses in the way in which the system is put into practice within healthcare institutions. The Order on Teaching Commissions of 1995<span class="elsevierStyleSup">15</span>, which regulates their powers and operation, as well as those of the directors of studies and tutors (educational supervisors), has not been thoroughly implemented<span class="elsevierStyleBold"> </span>and the evaluation system it proposed, the one currently operating, is more a system of certification of completion of a series of rotations or placements in certain care units, than a true training and assessment of competencies. A study by the National Commission on Nephrology revealed some of these weaknesses in the training of specialists, from irregular allocation of human and material resources within teaching units, to failures to fulfil teaching objectives and the role of mentoring (tutor), run on a voluntary basis, being little recognised<span class="elsevierStyleSup">16</span>. With the new law, Real Decreto 183/2008<span class="elsevierStyleSup">17</span>, the entire National Health System has had a great opportunity to develop and improve the system for specialised medical training, providing the framework for competency training and assessment, addressing, among other points, the challenges of multi-professional units, and a controversial but fundamental issue, the core curriculum. You must first be a doctor and only then a specialist.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">However, as noted by J. Cobo-Reinoso, the mere passing of legislation does not guarantee its successful implementation<span class="elsevierStyleSup">18</span>; this author highlights the elements that should comprise a residency programme for it to be both effective: <span class="elsevierStyleItalic">1) </span>the definition of a training programme consistent with training objectives; <span class="elsevierStyleItalic">2) </span>establishment of monitoring protocols<span class="elsevierStyleItalic">; 3) </span>adequate communication with tutors; <span class="elsevierStyleItalic">4) </span>a comprehensive assessment system, essentially educational, and more demanding; and <span class="elsevierStyleItalic">5) </span>quality control by the Teaching Commission. This is not possible without funding and a definitive consolidation of healthcare organisations, educational structures and training agents (directors of studies, tutors, trainers and other teaching staff), and, in Spain, this is the responsibility of the regional governments.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">PROFESSIONAL COMPETENCIES</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">M.O. Bunk defines competence as behaviour resulting from a set of attitudes, skills, abilities, knowledge and values that people use to deal with specific situations related to their life and profession<span class="elsevierStyleSup">19</span>. It is, in short, the effective ability to successfully carry out a clearly specified work activity. Professional competence is not a measure of the probability of success in the execution of a profession; it is a real and demonstrated ability that can be evaluated based on results.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The start of the competency movement can be traced back to a paper published in 1973 by David McClelland, who asserted that not only aspects such as knowledge and skills, but also feelings, beliefs, attitudes and behaviours can predict high work performance<span class="elsevierStyleSup">20</span>. We are referring to empathy, intuition, integrity, perception of reality, the spirit of community, self-confidence, flexibility, and the domain of the individual. These concepts are fully applicable to the world of healthcare and indeed are today recognised as being fundamental aspects of the competencies of a medical practitioner. A Gual <span class="elsevierStyleItalic">et al</span><span class="elsevierStyleSup">9 </span>agree with this, stating that for the future we require: physicians who adopt a critical approach, who are communicative and empathetic, individually and socially responsible, make decisions which are good for the patient and the health care system, leaders of the health team, competent, effective and safe, honest and reliable, committed to patients and the organisation; physicians who treat patients, not diseases. In summary, the competencies of a professional combine knowledge (Know), skills and abilities (know-how), attitudes and behaviours (how to act), and values and beliefs (how to be).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Faced with the aforementioned changes and challenges of the 21<span class="elsevierStyleSup">st</span> century, academic and health organisations in various countries began to define basic competencies for physicians in the 1990s and early 2000s including: Tomorrow’s Doctor<span class="elsevierStyleSup">21</span>and Scottish Doctor<span class="elsevierStyleSup">22 </span>(UK), CanMEDS Roles<span class="elsevierStyleSup">23,24</span> (Canada), the Outcome Project of the Accreditation Council for Graduate Medical Education<span class="elsevierStyleSup">25,26</span> (USA) and the Institute for International Medical Education (IIME) in New York<span class="elsevierStyleSup">27 </span>(Table 1). The competency domains defined in these models are perfectly applicable to any specialty. Specifically, CanMEDS and the Outcome Project define what all residents must demonstrate upon completing their training. Along these lines, in 2008 the Medical Teaching Unit at Cruces Hospital (in its Competency-based Postgraduate Medical Education (CBPME) project, which started in 2004)<span class="elsevierStyleSup">28</span> defined its model of «Being a Physician/Medical Professional» (Teaching Vision<span class="elsevierStyleSup">29</span>) for all specialties of the centre, based on the model of the IIME, and incorporating concepts from the Outcome Project, CanMEDS and the American Board of Medical Specialties<span class="elsevierStyleSup">30</span>. Table 2 summarises the model «Being a Physician/Medical Professional at Cruces Hospital», which is to be the foundation of our competency evaluation system.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">These approaches do not mean that doctors, to date, have not been trained in such competencies; the difference is that in the CBPME<span class="elsevierStyleItalic"> </span>project they are made explicit, and those competencies necessary to address changing social and healthcare needs are emphasised<span class="elsevierStyleSup">31</span>. Working with such a model facilitates the development and adaptation of the learning process (learning objectives derived from the competencies, activities, specific tasks, training plans, schedules, methodologies and teaching resources) and the implementation of a final competency assessment (outcome-based assessment). To bring about the changes required, it is very important that all professionals adopt the same approach and language, a task that will take time.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE EDUCATIONAL PROCESS IN THE CONTEXT OF THE WORKPLACE AND THE ROLE OF INSTITUTIONS IN PROFESSIONALISATION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Training in the workplace professionalises the resident by developing their understanding of the knowledge, skills, abilities, attitudes and values that are present, these days, in the medical profession. However, it can also de-professionalise, as it is difficult to implement educational practices in each and every care setting in which residents train. The workload and other factors associated with healthcare organisations and their management do not facilitate interaction between tutors and residents. Though the residents should not forget that they are primarily responsible for their own training and must be proactive, this climate occasionally leads tutors and staff to forget their teaching role and that the residents are professionals in training. Institutions must guarantee: <span class="elsevierStyleItalic">1) </span>the exercise of leadership from senior and middle management (directors of studies, heads of department, tutors); <span class="elsevierStyleItalic">2) </span>the planning and development of a teaching strategy, with the involvement of all relevant parties (tutors and staff), facilitating decision-making and accountability, including on the part of residents; <span class="elsevierStyleItalic">3) </span>the resources (structural, material, financial and organisational); <span class="elsevierStyleItalic">4) </span>the development of programmes integrated into the care system in accordance with a defined profile of medical specialist; and <span class="elsevierStyleItalic">5) </span>the qualitative and quantitative measurement of results. It is within this scheme that the tutor is essential as a manager of a programme of specialisation within the teaching strategy of the centre. Duties and training tasks should be specified in the training programme contracts of the centres and in the portfolio of services of teaching units. This is a reflection of the duty they have to society as accredited teaching institutions<span class="elsevierStyleSup">12</span>.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Therefore, the objective is to provide a professional with: <span class="elsevierStyleItalic">1) </span>broad and essential training, based on ethical values, behaviours and attitudes and that encompasses  humanistic, scientific and technical aspects; <span class="elsevierStyleItalic">2) </span>an understanding of the scientific method and ability to put it into practice, and to manage complexity and uncertainty; <span class="elsevierStyleItalic">3) </span>a command of scientific language and skills enabling the proper use of computer technology, to facilitate independent learning; and <span class="elsevierStyleItalic">4) </span>sufficient experience in the field of interpersonal relations to encourage initiative and teamwork, and the development of skills for personal relations and for effective democratic participation in society<span class="elsevierStyleSup">32</span>. To achieve this goal, healthcare centres and teaching units (clinical departments) should be aware that there must be consistency in the training process, taking into account the three stages of the teaching/learning cycle: before, during and after. <span class="elsevierStyleItalic">Before </span>provides for the social environment of the specialty, the skills to be developed by level, the role of the tutor, the resident, the other trainers and the institution. <span class="elsevierStyleItalic">During </span>(interaction) includes training contexts, how learning will be enhanced in each of the contexts; specific, joint and individual tasks; methodological strategies; and ongoing or formative evaluation. <span class="elsevierStyleItalic">After, </span>involves evaluation of the learning of the resident, tutor performance, the development of the training process, the programme, the trainers and other agents of the support structure<span class="elsevierStyleSup">32</span>. The tutor, as the pivotal figure in this complex process, with a high level of social responsibility, must acquire and develop certain teaching competencies<span class="elsevierStyleSup">33</span>.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">EVALUATION WITHIN THE TRAINING PROCESS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Concepts and general principles</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Rigorous and transferable evaluation is the great unmet challenge in the specialised training system, and it will never be possible if all training agents (not just the tutors) are not sure what to evaluate, i.e., if there is not a clearly defined programme with competencies to be achieved<span class="elsevierStyleSup">34 </span>(a professional profile, of the nephrologist in our case) and with instruments accepted throughout the institution. The evaluation (the <span class="elsevierStyleItalic">after</span>) is a moral obligation to society, the institution, and the resident (it is their right, for the purpose of guiding and supporting them in their learning, and in the acquisition and improvement of their competencies). Evaluation forms part of a complex training process and should be well defined a priori. Indeed, it is also a process in itself that generates data through assessment applying reference criteria, and this information is used to make judgments and decisions. These decisions can take many forms, but can be categorised under two broad types: a qualifying decision, a sanction, pass/fail, with no possibility of rectification, except by undergoing a new evaluation process (this type is called a <span class="elsevierStyleItalic">summative </span>assessment) and another type which can use the same instruments but is based on results. This latter type of evaluation allows the candidate to understand their strengths and weaknesses and create plans for improvement (it is known as <span class="elsevierStyleItalic">formative </span>assessment). Both demand an equal degree of rigor in their procedure and documentation. In the current training system, we must move away from the ingrained cultural concept of «pass/fail», and thoroughly develop formative assessment. It should be realised that an evaluation process tends to fail if the following questions have not been clearly answered beforehand<span class="elsevierStyleSup">34</span>: Which competencies are to be evaluated?. How? (with what instruments?). Why evaluate? (what is the objective?). When?. By whom?. With what resources?, and is there collaboration across the entire team?. Therefore,  every evaluation should conform to the following principles<span class="elsevierStyleSup">35</span>:<span class="elsevierStyleSup"> </span>it should<span class="elsevierStyleItalic"> </span>be; <span class="elsevierStyleItalic">1) </span>appropriate to the purpose (why?); <span class="elsevierStyleItalic">2) </span>based on the program content (what?); <span class="elsevierStyleItalic">3) </span>use methods selected in terms of validity, reliability and feasibility (based on the best available evidence); <span class="elsevierStyleItalic">4) </span>have standardised, transparent and public documentation and methods; <span class="elsevierStyleItalic">5) </span>provide important and positive feedback (educational evaluation); <span class="elsevierStyleItalic">6) </span>be overseen by evaluators with demonstrated ability and willingness to collaborate (who?); <span class="elsevierStyleItalic">7) </span>allow for lay people to assess or examine areas in which they are competent (e.g., communication, professionalism); <span class="elsevierStyleItalic">8) </span>receive sufficient resources, and <span class="elsevierStyleItalic">9) </span>have a comprehensive system of quality assurance. The evaluation should not be limited to the resident but rather must embrace the programme, process, structure and training agents, as the key to improvement.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">What to evaluate and how to assess the competencies of a professional</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Evaluation of residents has, as its objective, to improve and facilitate the development of knowledge, skills, abilities, attitudes and values. To achieve this objective will require ongoing assessment of the resident in their acquisition of knowledge, skills and attitudes, and monitoring of the successes or failures of the design and operation of the training programmes. The assessment of professional competence involves various dimensions that are reflected in actions<span class="elsevierStyleSup">22</span>: <span class="elsevierStyleItalic">1) </span>what the doctor is able to do: technical intelligences (clinical competencies and skills), <span class="elsevierStyleItalic">2) </span>how the doctor approaches their practice: intellectual (basic knowledge), emotional (attitude), the creative and analytical (reasoning) intelligences, and <span class="elsevierStyleItalic">3) </span>the doctor as a professional: personal intelligences (values, ethics, professionalism). There are many validated tools and methods to assess each of these areas, which when combined, allow us to judge the competence of a professional. A description of these and their application is beyond the scope of this article, and there are excellent reviews on the subject<span class="elsevierStyleSup">36,37</span>.  A particularly useful document is the Toolbox (Outcome Project, ACGME<span class="elsevierStyleSup">38</span>), which describes each instrument well, its underlying concept, psychometric qualities, utility, validity and reliability. Based on that document and grouping competencies into seven domains, as described in Table 2, the potential assessment tools for each domain would be:</p><p class="elsevierStylePara">1. <span class="elsevierStyleItalic">Professional values, attitudes, behaviour and ethics: </span>Multiple source feedback (MSF)<span class="elsevierStyleSup">39</span>, commonly used in the private sector, patient point of view, and objective structured clinical examination (OSCE)<span class="elsevierStyleSup">40</span>.</p><p class="elsevierStylePara">2. <span class="elsevierStyleItalic">Clinical skills (clinical healthcare expert): </span>standardised patients, simulations, OSCE, clinical evaluation by direct observation of clinical practice in the workplace (Mini-CEX - Mini-Clinical Evaluation Exercise, DOPs - Directly Observed Procedural Skills<span class="elsevierStyleSup">41,42</span>), questionnaires, case studies, clinical records, audits, peer reviews, quality indicators, reports, and portfolios<span class="elsevierStyleSup">43</span>. In relation to this, Cruces Hospital is developing its own model of reflective logbook/report to form the basis of future portfolios<span class="elsevierStyleSup">44,45</span>. Note, however, in terms of the clinical evaluation tests by direct observation, they have been developed in the Anglo-Saxon world to deal with a concern that Norcini highlights in his article<span class="elsevierStyleSup">41</span>, that the trainees are seldom observed, so the circumstances in our environment may be different.</p><p class="elsevierStylePara">3. <span class="elsevierStyleItalic">Scientific foundations of medicine (medical knowledge): </span>testing all types of knowledge, multiple-choice questions (MCQs), extended-matching items (EMIs)<span class="elsevierStyleSup">46</span>, structured cases, simulations and models.</p><p class="elsevierStylePara">4. <span class="elsevierStyleItalic">Communication: </span>patient opinions, MSF, standardised patients, and OSCE.</p><p class="elsevierStylePara">5. <span class="elsevierStyleItalic">Public health systems (health promoter and manager of resources): </span>MSF, questionnaires, and patient opinions.</p><p class="elsevierStylePara">6. <span class="elsevierStyleItalic">Information management: </span>computer simulations, and cases.</p><p class="elsevierStylePara">7. <span class="elsevierStyleItalic">Critical analysis and research, and self-directed learning: </span>portfolios, reflective reports, and standardised cases.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">To evaluate the competencies of a professional many dimensions must be considered, it being necessary to extrapolate from partial data to arrive at a complete picture. Nevertheless, we should start with very simple, inexpensive instruments, accepted and understood by all clinical staff and the resident, and that provide added value to our Postgraduate Medical Education system.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Specialised training based on competencies is the answer to a globalised world in permanent change. To take this forward, medical centres and services should develop their own projects, as allowed for within the existing regulatory framework. Health institutions should be aware of their duty to society given their accreditation as teaching bodies. However, if they are to exert effective leadership in the development of training programmes it is essential that structural, organisational and human resources are made available. In Spain, this is already provided for in current legislation, and the regional governments are responsible for implementing and developing this infrastructure without further delay.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">Acknowledgements to Pilar Martínez Clarés, Professor in the Department of Diagnostic and Research Methods applied to Education, Faculty of Education (University of Murcia) for her personal contribution to the content of this text, to the Tutors of the Competency Assessment Group (Andima Basterretxea, Elena Bereziartua, Milagros Iriberri and Agustín Martínez-Berriochoa) and to Mª Jesús González-García, secretary of the Medical Teaching Unit at Cruces Hospital.</p><p class="elsevierStylePara"><a href="10559_108_10783_en_10559_108_10783_en_w477710581710559_18107_7509_es_10559_18623_7509_es_tabla_1_en.doc" class="elsevierStyleCrossRefs">10559_108_10783_en_10559_108_10783_en_w477710581710559_18107_7509_es_10559_18623_7509_es_tabla_1_en.doc</a></p><p class="elsevierStylePara">Table 1. Models of competency domains</p><p class="elsevierStylePara"><a href="10559_108_10785_en_10559_108_10785_en_w477710581610559_7511_es_10559_18623_7511_es_tabla_2_en.doc" class="elsevierStyleCrossRefs">10559_108_10785_en_10559_108_10785_en_w477710581610559_7511_es_10559_18623_7511_es_tabla_2_en.doc</a></p><p class="elsevierStylePara">Table 2. Physicians/Professionals at Cruces Hospital (2008)</p>" "pdfFichero" => "P1-E506-S2871-A10559-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec441481" "palabras" => array:1 [ 0 => "Formación sanitaria especializada" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec441483" "palabras" => array:1 [ 0 => "Formación basada en competencias" ] ] ] "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441482" "palabras" => array:1 [ 0 => "Postgraduate Medical Education" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441484" "palabras" => array:1 [ 0 => "Competency-based Medical Education" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "<p class="elsevierStylePara">In a world undergoing constant change, in the era of globalisation, the training of medical professionals should be under constant review so that it can be tailored to meet the needs of this society in transition. This is all the more true at times of economic uncertainty, such as the current conditions, which have a direct impact on health services. Professionals need new Competencies for new times. Over the last decade initiatives have emerged in various Anglo-Saxon countries which have defined a framework of basic Competencies that all medical specialists should demonstrate in their professional practice. In addition to this, we must respond to the creation of the European Higher Education Area which has implications for specialised training. In Spain, training for medical specialists was in need of an overhaul and the recently passed law (Real Decreto 183/2008) will allow us to move forward and implement, in medical education, initiatives and innovations required in our medical centres, to respond to the new society and bring us in line with international professional education and practice. The way forward is a Competency-based model for medical education with assessment of these Competencies using simple instruments, validated and accepted by all the stakeholders. The institutions involved (hospitals, medical centres and other healthcare services) should trial different approaches within the general framework established by the current legislation and be conscious of the duty they have to society as accredited training organisations. Accordingly, they should consolidate their teaching and learning structures and the various different educational roles (directors of studies, tutors, and other teaching positions), showing the leadership necessary to allow proper implementation of training programmes. For this, the Spanish regional governments must develop their own legislation regulating Medical Specialty Training. So, medical professionals should receive training, based on ethical values, behaviours and attitudes that considers humanistic, scientific and technical factors, developing an understanding of the scientific method and ability to put it into practice; skills to manage complexity and uncertainty; a command of scientific, technical and IT terminology, to facilitate independent learning; and a capacity for initiative and teamwork, as well as skills for personal activities and for making an effective, democratic contribution both within health organisations and in the wider society.</p>" ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara">En un mundo globalizado y en permanente cambio, la formación de profesionales de la medicina exige una reflexión continua para dar respuesta a esa sociedad en continua transición, máxime cuando se viven momentos económicos tan delicados como el actual que influyen directamente en el mundo sanitario. Los profesionales precisan nuevas competencias para nuevos tiempos. En la última década han surgido iniciativas en distintos países del mundo anglosajón que han definido el marco de competencias básicas necesarias que todo médico y especialista debe demostrar en su práctica profesional. Junto a ello nos encontramos ante el Espacio Europeo de Educación Superior que también influye en nuestra formación especializada. La formación sanitaria especializada en España precisaba un nuevo impulso y el reciente marco regulatorio (Real Decreto 183/2008) nos permitirá avanzar y desarrollar aquellas iniciativas e innovaciones que en educación médica son imprescindibles implantar en los centros sanitarios, para responder a una nueva sociedad y adecuarnos al contexto educativo y de práctica profesional internacional.</p> <p class="elsevierStylePara">La formación médica basada en competencias y su evaluación con instrumentos, sencillos, validados y aceptados por todos los agentes implicados en la formación, es el camino a seguir. Las instituciones (centros y servicios asistenciales) deberán desarrollar sus propias experiencias dentro del marco general que proporciona la legislación vigente, y estas instituciones deben ser conscientes del compromiso adquirido con la sociedad a través de la acreditación docente, debiendo, por tanto, consolidar su organización docente y las distintas figuras de los agentes formadores (jefes de Estudio, tutores y otras figuras docentes), ejerciendo el necesario liderazgo para el completo desarrollo de los programas formativos. Para ello, es preciso que las Comunidades Autónomas desarrollen sus propias normativas en formación sanitaria especializada.</p> <p class="elsevierStylePara">Por tanto, los profesionales de la medicina deben tener una formación basada en: valores éticos, hábitos y actitudes que abarque aspectos humanísticos, científicos y tecnológicos; un conocimiento y una práctica del método científico, unidos a la gestión de la complejidad y de la incertidumbre; un manejo correcto del lenguaje científico, tecnológico e informático que facilite el aprendizaje autónomo; una capacidad de iniciativa y trabajo en equipo, así como el desarrollo de habilidades para los asuntos personales y para una eficaz participación democrática en la sociedad y en las instituciones sanitarias.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "mmc1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "Ecomponente" => array:2 [ "fichero" => "10559_108_10783_en_10559_108_10783_en_w477710581710559_18107_7509_es_10559_18623_7509_es_tabla_1_en.doc" "ficheroTamanyo" => 26112 ] "descripcion" => array:1 [ "en" => "Models of competency domains" ] ] 1 => array:8 [ "identificador" => "mmc2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "Ecomponente" => array:2 [ "fichero" => "10559_108_10785_en_10559_108_10785_en_w477710581610559_7511_es_10559_18623_7511_es_tabla_2_en.doc" "ficheroTamanyo" => 25088 ] "descripcion" => array:1 [ "en" => "Physicians/Professionals at Cruces Hospital (2008)" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:48 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ruiz de Gauna P. La formación médica en una sociedad globalizada. En: Fonseca M, Ruiz de Gauna P (eds). Avances en Educación Médica: Retos presentes para futuros profesionales de las ciencias de la salud.\u{A0}Ponencias del I Congreso SEMDE, 22-25 de junio de 2004.Bilbao: Sociedad de Educación Médica de Euskadi (SEMDE),\u{A0}2005;\u{A0}2: 21." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "http://www.ehu.es/SEMDE/archivos_pdf/avances_ed_medica.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mardones JM. Educar para una sociedad más humana: la educación ante la economía y la cultura. Retos educativos para la próxima década en la Unión Europea y sus implicaciones organizativas: VII Congreso Interuniversitario de Organización de Instituciones Educativas (VII CIOIE). San Sebastián, 4-6 de julio de 2002;\u{A0}81-96." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "The Bologna Declaration of 19 June 1999. http:// www.bologna-bergen2005.no/Docs/00-Main_doc/990719 BOLOGNA_DECLARATION.PDF" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Stein G. Peter Drucker (I). Hacia una biografía intelectual. En: Instituto Empresa y Humanismo (Cuadernos Empresa y Humanismo n.º 73). http://www.unav.es/empresayhumanismo/publicaciones/cuadernos/catalogo07.htm" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "5.\u{A0}Libro Blanco de las profesiones sanitarias de Cataluña. Generalitat de Catalunya. Departamento de Sanidad y Seguridad Social. B-18.688-2003; p. 69." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Jovell A. El futuro de la profesión médica. Fundació Biblioteca Josep Laporte 2001. http://www.fbjoseplaporte.org/docs/repositori/070517121543.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Jovell A, Navarro M. La profesión médica en la encrucijada: hacia un nuevo modelo de gobierno corporativo y contrato social (2006). http://www.fbjoseplaporte.org/docs/repositori/070727130419.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "8.\u{A0}Ser Médico, hoy. Retos del nuevo profesionalismo médico en España. Informe de la Fundación Educación Médica para el Consejo General de Colegios Oficiales de Médicos. Madrid 2006 http://www.educacionmedica.net/sec/serMedico 2006.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Gual A, Oriol-Bosch A, Pardell H. El médico del futuro.\u{A0}Med Clin (Barc) 2010;134:363-8." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "10.\u{A0}Martínez-Clares P, Martínez-Juarez M,\u{A0}Muñoz-Cantero JM. Formación basada en competencias en educación sanitaria: aproximaciones a enfoques y modelos de competencia. RELIEVE 2008;14(2):1-23. (www.uv.es/RELIEVE)" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "11.\u{A0}Echeverría B. Gestión de la competencia de Acción Profesional. Revista de Investigación Educativa 2002;20(1):7-43." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Morán Barrios J. ¿Es necesaria y compatible la existencia del tutor de médicos residentes dentro de nuestras estructuras asistenciales? Educ Med 2003;6(3):10-1." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sistema Español de Formación Especializada. Evolución, Situación actual y Perspectivas de futuro (n.º de expediente 713/000155). En: Sesión Informativa de la Comisión de Sanidad y Seguridad Social de 30 de junio de 1992, Diario de Sesiones del Senado: Comisión n.º 190, 1992." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "14.\u{A0}Real Decreto 127/1984, de 11 de enero, por el que se regula la formación médica especializada y la obtención del título de médico especialista. (Vigente hasta el 22 de febrero de 2008). BOE número 26 de 31/1/1984;2524-8." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Orden de 22 de junio de 1995 por la que se regulan las Comisiones de Docencia y los sistemas de evaluación de la formación de Médicos y Farmacéuticos especialistas. www.boe.es/boe/dias/1995/06/30/pdfs/A19793-19799.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Quereda C. por la Comisión Nacional de la especialidad de Nefrología (Ortega F, Martín de Francisco A. L., Matesanz R, Alcázar R, Sanz Boix A, Bernis C, Abaigar P, Sanchez Casajús A, Mérida E, García Pérez M.A.). Algunos aspectos de la situación de la formación de especialistas de Nefrología en España. Nefrología 2008; 28 (3) 263-271 <a href="http://www.ncbi.nlm.nih.gov/pubmed/18590492" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Real Decreto 183/2008, de 8 de febrero, por el que se determinan y clasifican las especialidades en Ciencias de la Salud y se desarrollan determinados aspectos del sistema de formación sanitaria especializada. www.msc.es/profesionales/formacion/docs/realDecreto183_2008.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cobo-Reinoso J. La difícil transición de licenciado a especialista. Educ Med 2009;12(Supl 3):S45-S50." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Bunk GP. Teaching Competente in Initial and Continuing Vocational Training in the Federal Republic of Germany. Vocat Train Eur J 1994;1:8-14." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "McClelland D. Testing for Competence rather than for Intelligence. Am Psychol 1973;28(1):1-14. <a href="http://www.ncbi.nlm.nih.gov/pubmed/4684069" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Tomorrow´s Doctor. www.gmc-uk.org/education/undergraduate/tomorrows_doctors.asp" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "The Scottish Doctor Project 2000.\u{A0} http://www.scottishdoctor.org/resources/scotdoc1.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "CanMEDS 2000: Extract from the CanMEDS 2000 Project Societal Needs Working Group Report. Medical Teacher, 2000;22(6):549-54, y CanMEDS 2005 Framework. http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf <a href="http://www.ncbi.nlm.nih.gov/pubmed/21275687" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 24 => array:3 [ "identificador" => "bib25" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "24.\u{A0}Frank\u{A0} JR,\u{A0}Danoff D. The CanMEDS initiative.: implementing an outcomes-based framework of physician competencies. Medical Teacher 2007;29(7):642-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18236250" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 25 => array:3 [ "identificador" => "bib26" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "25.\u{A0} An Introduction to Competency-based Residency Education. ©2006 ACGME. A product of the ACGME Outcome Project, 2006; http://www.acgme.org/outcome/comp/compCPRL.asp" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 26 => array:3 [ "identificador" => "bib27" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "26.\u{A0}Swing SR. The ACGME outcome Project: retrospective and prospective. Medical Teacher 2007;29:648-54. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18236251" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 27 => array:3 [ "identificador" => "bib28" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Institute for International Medical Education, Core Committee. Global Minimum Essential Requirements in Medical Education. Medical Teacher 2002;24:130-5. Traducción al español en la revista Educación Médica 2003;6(Supl. 2):11-9." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 28 => array:3 [ "identificador" => "bib29" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Morán Barrios J. Competencia profesional de médicos especialistas y modelo de gestión de la formación médica especializada basado en la experiencia del Hospital de Cruces. En: Fonseca M, Ruiz de Gauna P (eds.). Avances en Educación Médica: Retos presentes para futuros profesionales de las ciencias de la salud. Ponencias del I Congreso SEMDE. San Sebastián, 22-25 de junio de 2004. Bilbao:\u{A0}Sociedad de Educación Médica de Euskadi (SEMDE),\u{A0}2005;9:83." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 29 => array:3 [ "identificador" => "bib30" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "http://www.ehu.es/SEMDE/archivos_pdf/avances_ed_medica.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 30 => array:3 [ "identificador" => "bib31" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Morán Barrios J. Ser Médico. http://www.hospitalcruces.com/documentos/actividadDocente/VISION_DOCENTE-SER_MEDICO.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 31 => array:3 [ "identificador" => "bib32" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "American Board Medical Specialties. MOC Competencies and Criteria: http://www.abms.org/Maintenance_of_Certification/ABMS_MOC.aspx" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 32 => array:3 [ "identificador" => "bib33" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Morán Barrios J. La Formación basada en competencias debe de introducirse también en la Formación Especializada (entrevista). DPM 2010;3(1):37-40. http://www.idepro.es/dpm/v3_n1/DPM3_1.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 33 => array:3 [ "identificador" => "bib34" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Fonseca M, Ruiz de Gauna P. Formación médica especializada: formar en competencias para incidir en el perfil del profesional que necesita la sociedad y la sanidad del siglo XXI. En Perspectivas para el Cambio en la Formación y la Práctica Médica, pág 67-71. Bilbao, 26-27 de octubre de 2006: II Congreso de la Sociedad de Educación Médica de Euskadi (SEMDE). http://www.ehu.es/SEMDE/publi.htm" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 34 => array:3 [ "identificador" => "bib35" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "33.\u{A0}Saura Llamas J.\u{A0}Cómo puede convertirse un tutor en un docente efectivo. Aten Primaria 2007;39(3):151-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17386208" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 35 => array:3 [ "identificador" => "bib36" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Morán Barrios J. Estrategias e instrumentos de evaluación del residente. Valladolid, 8 y 9 de octubre de 2008: Ponencia Jornada de Tutores de Formación Sanitaria Especializada de Castilla y León.\u{A0}http://www.ehu.es/SEMDE/publi.htm" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 36 => array:3 [ "identificador" => "bib37" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "35.\u{A0}A working paper from the Postgraduate Medical Education Training Board. Principles for an assessment system for postgraduate medical training 14 September 2004.\u{A0}http://www.ecompendium.nhs.uk/PMETB-principles-for-assessment-systems.asp" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 37 => array:3 [ "identificador" => "bib38" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Epstein RM. Assessment in Medical Education. N Engl J Med 2007;356:387-96. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17251535" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 38 => array:3 [ "identificador" => "bib39" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wass V, Van der Vleuten C, Shatzer J, Jones R. Assessment of clinical competence. Lancet 2001;357:945-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11289364" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 39 => array:3 [ "identificador" => "bib40" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "ACGME Outcome project. Toolbox of assessment methods: http://www.acgme.org/Outcome/assess/Toolbox.pdf" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 40 => array:3 [ "identificador" => "bib41" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Whitehouse A, Hassell A, Bullock A,\u{A0} Wood L, Wall D. 360 degree assessment (multisource feedback) of UK trainee doctors: Field testing of team assessment of behaviours (TAB). Medical Teacher 2007;29(2-3):171-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17701629" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 41 => array:3 [ "identificador" => "bib42" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "40.\u{A0}Martínez Carretero JM. Los métodos de evaluación de la competencia profesional: la evaluación clínica objetiva estructurada (ECOE). Educ Med 2005;8(Supl 2):S18-S22." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 42 => array:3 [ "identificador" => "bib43" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Norcini \u{A0}J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Medical Teacher 2007;29(9-10):855-71." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 43 => array:3 [ "identificador" => "bib44" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "42.\u{A0}Norcini J. The Mini Clinical Evaluation Exercise (mini-CEX). Clinical Teacher 2005;2(1):25-30." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 44 => array:3 [ "identificador" => "bib45" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Snadden D, Thomas M. The use of portfolio learning in medical education. Medical Teacher 1998;20(3):192-9." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 45 => array:3 [ "identificador" => "bib46" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Morán J, Fernández F, Lorenzo M, Sharluyan A. Memoria de Formación del Médico Residente (MFMIR). Aproximación al portafolio docente. Educ Med 2005;8(3):159. (I-8)." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 46 => array:3 [ "identificador" => "bib47" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Moran j, Carballo G, Ruiz de Gauna P. Contenido reflexivo de la memoria de formación MIR del Hospital de Cruces. Bases del portafolio formativo. Educ Med 2007; 10(3):169. D-6." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 47 => array:3 [ "identificador" => "bib48" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "46.\u{A0}Case SM, Swanson DB. Extended-matchiong items: A practical alternative to free-response quiestions. Teaching and Learning in Medicine 1993;5(2):107-15." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003000000006/v0_201502091649/X2013251410051005/v0_201502091649/en/main.assets" "Apartado" => array:4 [ "identificador" => "35446" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003000000006/v0_201502091649/X2013251410051005/v0_201502091649/en/P1-E506-S2871-A10559-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410051005?idApp=UINPBA000064" ]
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| 2016 June | 134 | 0 | 134 |
| 2016 May | 129 | 0 | 129 |
| 2016 April | 98 | 0 | 98 |
| 2016 March | 105 | 0 | 105 |
| 2016 February | 137 | 0 | 137 |
| 2016 January | 103 | 0 | 103 |
| 2015 December | 139 | 0 | 139 |
| 2015 November | 106 | 0 | 106 |
| 2015 October | 86 | 0 | 86 |
| 2015 September | 69 | 0 | 69 |
| 2015 August | 89 | 0 | 89 |
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| 2015 June | 45 | 0 | 45 |
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