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Editorial  |   September 2016
Redefining Competency Domains for Osteopathic Medical Practice
Author Notes
  • Financial Disclosures: Dr Gimpel is the president and chief executive officer of the National Board of Osteopathic Medical Examiners. 
  •  * Address correspondence to John R. Gimpel, DO, MEd, President and Chief Executive Officer, National Board of Osteopathic Medical Examiners, 101 W Elm St, Suite 230, Conshohocken, PA 19428-2075. E-mail: communications@nbome.org
     
Article Information
Medical Education / Professional Issues / Graduate Medical Education / COMLEX-USA
Editorial   |   September 2016
Redefining Competency Domains for Osteopathic Medical Practice
The Journal of the American Osteopathic Association, September 2016, Vol. 116, 568-570. doi:10.7556/jaoa.2016.113
The Journal of the American Osteopathic Association, September 2016, Vol. 116, 568-570. doi:10.7556/jaoa.2016.113
Over the past 20 years, there has been a growing national and international trend toward developing frameworks for defining, applying, teaching, and measuring the competence of physicians. To answer this call, in 2006, the National Board of Osteopathic Medical Examiners (NBOME) issued a detailed report1 on physician competencies for osteopathic medical practice from the licensure assessment perspective. Subsequent versions of the report, which garnered substantial input from across the osteopathic medical profession and featured fundamental osteopathic medical competencies and competency domains, were published in 20092 and 2011.3 
The Fundamental Osteopathic Medical Competency Domains 20164 (FOMCD 2016), which comailed with this September 2016 issue of The Journal of the American Osteopathic Association and is available online at http://online.flipbuilder.com/ebwc/wnza, represents the NBOME’s most recent work: facilitating expert consensus on the required elements and measured outcomes for 7 core competency domains as related to the practice of osteopathic medicine. Expert consensus was informed by research related to the practice of osteopathic medicine and evidence-based competency domains required for safe and effective osteopathic medical care of patients.5 Through FOMCD 2016, the NBOME outlines these domains predominantly from the assessment perspective, particularly as they relate to summative high-stakes assessment for licensure for osteopathic medical practice. Substantial attention was given to professionalism and trustworthiness, interprofessional collaboration and care in teams, self-care and physician wellness, systems-based practice, practice-based learning and improvement, patient safety, and clinical procedures. 
Between the release of the FOMCD 2011 and FOMCD 2016, efforts to delineate the progression of a physician-in-training toward an expected level of proficiency in his or her competency development, or “milestones,” were put forth by the Accreditation Council for Graduate Medical Education (ACGME) and other professional groups.6 While milestones are designed and currently used for formative assessment of learner development and the overview of residency programs, the ACGME has cautioned against the use of milestones for summative purposes or in residency program accreditation.7 Another important development was the announcement in February 2014 by the ACGME, the American Osteopathic Association, and the American Association of Colleges of Osteopathic Medicine (AACOM) to collaborate over the ensuing 5 years on the development of a single accreditation system for residency and fellowship training programs in the United States.8 The new single accreditation system for graduate medical education (GME)9 adds osteopathic milestones for residency programs that apply for osteopathic recognition within the ACGME.10 The single accreditation system also embraces osteopathic distinctiveness and competency-based assessment frameworks, including the recognition and acceptance of the Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) series for the licensure of osteopathic physicians (ie, DOs). 
In addition to milestones, other newer frameworks for assessment have emerged that have the potential to broaden the overall development of physicians for entrustment in practice. One example is entrustable professional activities (EPAs),11,12 and both milestones and EPAs are introduced in FOMCD 2016. Additional research and collaboration is anticipated, aimed at potential harmonization and continuous quality improvement for teaching, learning, and practice. For example, earlier this year, AACOM published a resource to guide curriculum development relative to core EPAs at colleges of osteopathic medicine.13 
Ultimately, the goal is to further improve patient care and public health. In addition to supporting transparency for examinees and other stakeholders and providing assurance to patients, FOMCD 2016 serves to inform the enhanced, competency-based COMLEX-USA Master Blueprint 2018-201914 for the COMLEX-USA series, which consist of the examinations that are designed and used for licensure for DOs and other important purposes (eg, graduating from a college of osteopathic medicine, applying to residency training). 
Although FOMCD 2016 has helped to inform the new COMLEX-USA Master Blueprint, they are not completely interchangeable. For example, FOMCD 2016 substantially informs the Competency Domains dimension of the COMLEX-USA Master Blueprint, whereas the COMLEX-USA Master Blueprint will assess examinees across all 7 domains of competency and associated required elements and measured outcomes outlined in FOMCD 2016. Attested outcomes delineated in FOMCD 2016 provide an opportunity for future harmonization with workplace assessment in the undergraduate medical education or GME arenas. 
As with the competency domains outlined in FOMCD 2016, the Clinical Presentations dimension of the COMLEX-USA Master Blueprint was designed in an evidence-based manner to sample from the ways in which patients present to DOs in practice. This sampling has been expanded to include patient ages across the lifespan, varied clinical settings, and a broad range of diverse and special populations. 
The COMLEX-USA Master Blueprint, which will take effect beginning with the 2018-2019 academic year, will expand in an attempt to broaden the information collected at each of 2 examination decision points. Decision points are collections of individual assessments that align around 2 specific determinations in physician development for licensure decisions. With Decision Point 1, examinees must qualify for entry into residency training and supervised medical practice as residents, qualify for eligibility for GME training and licensure, and be aligned to receive the DO degree as determined by the students’ osteopathic medical schools. The 3 examinations within Decision Point 1 are COMLEX-USA Level 1, COMLEX-USA Level 2-Cognitive Evaluation, and COMLEX-USA Level 2-Performance Evaluation. All 3 examinations and other requirements must be successfully completed to qualify to enter Decision Point 2. 
The second determination in the enhanced COMLEX-USA series is Decision Point 2, which, starting in the 2018-2019 academic year, will be composed of a 2-day COMLEX-USA Level 3. This enhanced 2-day Level 3 examination, along with state-specific requirements including those pertaining to GME, qualifies DOs for eligibility for unrestricted medical licensure (often referred to as licensure for unsupervised medical practice) in all 50 United States. Additional information about the COMLEX-USA Master Blueprint, as well as for each specific examination in the COMLEX-USA series with test specifications and other requirements, are available on the NBOME website (http://www.nbome.org/comlex-cbt.asp?m=can). 
The Fundamental Osteopathic Medical Competency Domains 2016 serves to clarify the ramifications of the single accreditation system for GME, provide transparency in testing, and focus on osteopathic distinctiveness, among many other purposes. The NBOME anticipates and welcomes feedback from the osteopathic medical profession as we continue to keep pace with the evolving practice of osteopathic medicine while remaining ever true to the osteopathic tenets of caring for the whole patient and improving patient care and public health. 
Acknowledgments
The NBOME would like to acknowledge the members of its Blue Ribbon Panel on Enhancing COMLEX-USA, its Board of Directors, and its 1000-member National Faculty, for their expertise and collaborative efforts in producing FOMCD 2016. The Blue Ribbon Panel included representatives from the American Osteopathic Association, AACOM, the ACGME, the Association of Osteopathic Directors and Medical Educators, the Organization of Program Director Associations, the Federation of State Medical Boards, and the American Association of Osteopathic Examiners. 
References
National Board of Osteopathic Medical Examiners. The Seven Osteopathic Medical Competencies: Considerations for Future Testing and the Practice of Osteopathic Medicine. Chicago, IL: National Board of Osteopathic Medical Examiners; 2006. https://license.k3systems.com/LicensingPublic/docs/OsteopathicCompetenciesSeptember2006.pdf. Accessed May 9, 2016.
National Board of Osteopathic Medical Examiners. The Fundamental Osteopathic Medical Competencies: Guidelines for Osteopathic Medical Licensure and the Practice of Osteopathic Medicine. Chicago, IL: National Board of Osteopathic Medical Examiners; 2009.
National Board of Osteopathic Medical Examiners. The Fundamental Osteopathic Medical Competency Domains: Guidelines for Osteopathic Medical Licensure and the Practice of Osteopathic Medicine. Chicago, IL: National Board of Osteopathic Medical Examiners; 2011. https://www.nbome.org/docs/NBOME%20Fundamental%20Osteopathic%20Medical%20Competencies.pdf. Accessed March 1, 2016.
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Allopathic and osteopathic medical communities commit to a single graduate medical education accreditation system [news release]. Chicago, IL: American Osteopathic Association; February 26, 2014. http://www.osteopathic.org/inside-aoa/news-and-publications/media-center/2014-news-releases/Pages/2-26-allopathic-and-osteopathic-medical-communities-commit-to-single-graduate-medical-education-accreditation-system.aspx. Accessed August 4, 2016.
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Accreditation Council for Graduate Medical Education and the American Osteopathic Association. The Osteopathic Recognition Milestone Project. Chicago, IL: Accreditation Council for Graduate Medical Education; 2015. https://www.acgme.org/Portals/0/PdFs/Milestones/OsteopathicrecognitionMilestones.pdf. Published Accessed May 9, 2016.
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Osteopathic Considerations for Core Entrustable Professional Activities (EPAs) for Entering Residency. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2016.
COMLEX-USA master blueprint. National Board of Osteopathic Medical Examiners website. http://www.nbome.org/docs/COMLEX_Master_Blueprint_2018-2019.pdf. Accessed August 4, 2016.