Competency-based Training and the Competency Framework in Gynecology and Obstetrics in Brazil

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Although the idea of developing professional competency had been mentioned since the 1970s and 1980s, 1,2 the term medical competency remained undefined until the 2000s, when a broad literature review was published with the aim to clarify its meaning. 3 In 2002, the result of this study was published in JAMA by Epstein and Hundert, 3 and medical competency was defined as "the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community to be served." This made it clear how much the concept of competency differs from skill. The latter is used to designate the ability to perform specific technical-cognitive acts and actions such as intrauterine device insertion, obstetric examination, delivery care maneuvers, and the communication of bad news. The concept of competency is broader and includes the integration of knowledge, skills, and attitudes. 3,4 Therefore, medical competency is a multidimensional term and comprises a set of cognitive, technical, integrative, interpersonal, and affective-moral domains, as well as mental habits. 3 Some aspects concerning the subcomponents of medical competency based on the definition of Epstein and Hundert (2002) 3 stand out: Acquisition and use of knowledge: although evidencebased medicine is the major source of reliable knowledge for clarifying clinical doubts, the tacit, heuristic, and recognition-based knowledge is also greatly important for developing clinical competencies. Personal experience with clinical cases remains a great source of cognitive learning for physicians. 3 Integrative aspects of care: professional competency is not simply the demonstration of isolated clinical skills but their integration. When observing the medical activity as a whole, there is a difference between integrated technical skills and their isolated observation. A resident physician who evaluates the parturient according to the precepts of the partogram and demonstrates technical ability to perform delivery maneuvers at isolated times, may not provide adequate care during delivery when the integration of these two skills is needed. According to Friedman et al, 5 a competent professional is able to think and act as a physician. Schon argues that professional competency is more than the ability to solve clinical problems using shortcuts and factual knowledge, but extends to the ability to deal with uncertain, challenging situations and make decisions from a limited set of information. 6 Coping with these situations requires the mobilization of scientific, clinical, and humanistic expertise for guiding judgment and decisions. 7 Stimulating reflection on the practice performed by the resident physician through feedback from his or her supervisor promotes the development of integrative skills for the integration of knowledge and proper management of uncertainties. 3 Interpersonal relationship and communication skills: the quality of the communication and relationship established between the physician and the patient interferes with health status, recovery, control of chronic diseases and treatment costs. Proper communication with patients favors a better understanding of their health conditions and a reduction in the degree of anxiety. 8 The person-centered care is guided by qualified listening, response to their feelings, and the inclusion of patients and their values in the definition of the therapeutic plan. Teamwork skills are critical for patient safety and most medical errors result from failures in these skills. 3 Affective-moral dimensions: the evaluation of the affective-moral domain is a difficult one because it involves subjective characteristics, such as trust and professionalism. Neurobiological studies indicate the affective component is central for judgment and decision making; hence, emotional intelligence is a fundamental skill for medical practice. 3 Mental habits: professional competency requires mental habits that promote attention, investigative curiosity, selfawareness, and the initiative to recognize and correct one's own mistakes. Competent practitioners should be able to identify their degree of anxiety in the face of uncertainty and assess how much their emotional state may interfere with clinical judgment. From this point of view, medical errors can result from overestimated security in the face of uncertain situations. 3 Context: competency is context-dependent and involves the professional's personal skills, the patient's characteristics, the activity performed, the work environment and the health system in which the activity is inserted. 3 The medical education reform movement has been a recurring theme in scientific literature and the subject of several proposals since the 1910 Flexner report. [9][10][11] In the late 1990s, the 'To err is human' report published by the Institute of Medicine (IOM) 10 in the United States showed that even with the 20 th century advances, healthcare in the country was not so safe. Such a report was produced from results of two large studies and showed estimates of preventable deaths caused by medical errors between 44,000 and 98,000 a year in the United States, that is, even the smallest estimates outnumbered deaths from traffic accidents, breast cancer, and AIDS. 10 These results created a movement by society and regulatory agencies in the direction of placing competency-based medical education (CBME) as a priority. 1,2,9 The aim of this change was to train better prepared professionals for the challenges of modern medicine. In the early 1990s, the Royal College of Physicians and Surgeons approved the CanMEDS Physician Competency Framework, which was revised and has been adopted as a standard for medical education in Canada since 2005. 12 Following this trend, in 1999, the Accreditation Council for Graduate Medical Education (ACGME) developed the competency framework for undergraduate medical education in the United States (Outcome Project), which was adopted as a reference for medical education in that country in 2001. 13,14 The National Accreditation System of American medical schools was also restructured based on these competencies (the Next Accreditation System -NAS), and became effective in 2013. 15 In the United Kingdom, the medical education reform had already begun in 1993, with publication of the 'Tomorrow's doctor' document. This document was revised in 2002, 16 2009, 17 and 2018. 18 The latter was called 'Outcomes for graduates', and corresponds to the current competency framework for undergraduate medicine in the UK. 18 These countries were the first to require that residency programs were also competency driven. 2 The certification exams for obtaining a specialist title and professional license have also become guided by competency assessment. 9,13,19 This change meant the transition from a knowledge-based training system with exposure to specific content to a competency-based system. Training based on the acquisition of knowledge presupposes a predefined duration of the discipline so that a certain content can be assimilated by all learners. Competency-based training, on the other hand, establishes levels of competencies (milestones) that must be acquired and demonstrated by learners so they can progress independently from their peers. Knowledge-based training is more static and focused on disciplinary content, while competency-based training is more dynamic, learner-centered and requires greater flexibility in curricula and training programs. In knowledge-based training, the assessment process is performed at the end of each block, internship, or discipline with the aim to check content assimilation ("learning" assessment). In competency-based training, the assessment process is formative ("for learning" assessment), with the aim to check skills acquired from observing residents' performance, which includes, in addition to knowledge, the integration of procedural skills, communication and attitudinal components. 20 The shift from knowledgebased to competency-based training has been considered the Flexnerian Revolution of the 21 st century. 9 Worldwide, medical education and competency-based training are advancing for improving patient safety and training physicians committed to professionalism, continuing education, and social responsibility. 2,11 In 2014, the ACGME, the American Board of Obstetrics and Gynecology (ABOG), and the American Congress of Obstetricians and Gynecologists (ACOG), in partnership with the NAS, published the Milestones Project, 21 a framework of core competencies to guide Gynecology and Obstetrics medical residency programs in the United States. The document has 28 competency axes hierarchized in 5 performance levels (milestones). Each milestone corresponds to a training stage that extends from apprentice level (level 1) to expert level (level 5). 21 Other countries, such as Canada, the United Kingdom, Australia, and the Netherlands, have also published competency frameworks for gynecologist and obstetrician training based on essential competencies for professional practice in each country. 22 In Brazil, the legislation also followed this trend. In 2016, the Federal Council of Medicine and the Ministry of Education established that in all public notices of concourses for specialist titles in Brazil, the Brazilian Medical Association must observe the competency framework and the minimum specialization training time." 23 Faced with the need to reorient and qualify the training of gynecologists and obstetricians in Brazil, the Scientific Board of the Brazilian Federation of Gynecologic and Obstetrics Associations (FEBRASGO) took the initiative to develop the first version of the Gynecology and Obstetrics Competency Framework in Brazil. In 2016, the initial version was developed from national references, such as curricular guidelines of the Gynecology and Obstetrics Medical Residency Programs, 24 and international references, such as the ACOG Milestones Project. 21 The initial document underwent a validation process involving an expert panel, in which more than 200 experts from 29 Febrasgo National Specialty Commissions carefully assessed the axes of competencies, issued opinions and suggestions through a structured form. In the light of experts' suggestions, the Gynecology and Obstetrics Competency Framework was completed with 21 Axes of Competencies, including Professionalism and Patient Safety. Competencies were hierarchized into three levels of complexity corresponding to the first, second, and third year of training in Gynecology and Obstetrics, with identification of their subcomponents as knowledge (K), skills (S), and attitudes (A).
In 2017, the Gynecology and Obstetrics Competency Framework was published in Portuguese 25 and made available on the Febrasgo Web site. In 2018, this document was approved by the Brazilian Medical Association and the National Commission for Medical Residency and became the guide for Gynecology and Obstetrics Medical Residency Programs throughout Brazil. 26 In 2019, the Brazilian Gynecology and Obstetrics Competency Framework was extensively revised and updated was updated by the FEBRASGO National Specialized Commissions, the FEBRASGO Medical Residency Commission and expert consultants. 27 The updated version contains 16 Axes of Competence in Clinical and Surgical Obstetrics and Gynecology, including the Axes of Professionalism and Patient Safety.
Each axis presents the expected competencies for the resident at the end of the 1 st (R1), 2 nd (R2), and 3 rd (R3) years of residency in Gynecology and Obstetrics. The competencies for R2 are cumulative, compared with R1, and competencies for R3 are cumulative, with respect to R1 and R2. The subcomponents in each competency-axis were identified as Knowledge (K), Skills (S), or Attitudes (A) (►Boxs 1-16).

Conclusion
Brazil is a country of continental dimensions that presents great regional differences in terms of the availability of human and economic resources as well as in the social profile of patients. The orientation of residency programs by the Competence Framework will demand a lot of atten-tion from supervisors and preceptors, not only in the transfer of technical knowledge, but also in the reorientation of practices and in communication with other professionals. It is necessary for the educational institutions that maintain the residency programs to make investments in infrastructure and the training of preceptors and supervisors. Competency-based medical education is an integrated, progressive, learner-centered training strategy focused on assessment of the expected performance for the physician's clinical practice. It emphasizes learners' continuing education and accountability for their development through formative assessment. The Gynecology and Obstetrics Competency Framework is an important reference for harmonizing and qualifying medical residency programs throughout Brazil, as well as guiding the resident's training and evaluation processes, and the certification of Gynecology and Obstetrics specialists.
14 Swing SR. The ACGME outcome project: retrospective and prospective. General goal: Acquisition of competencies related to low and high-risk obstetrical care and common complications during pregnancy.

R1
-Demonstrates knowledge of adaptations of women to pregnancy and changes in the pregnancypuerperal cycle; General goal: acquisition of competencies related to the care of women with breast disorders.

R1
-Demonstrates knowledge of the most common benign and malignant breast disorders (cyclic and noncyclic breast pain, fibrocystic breast changes, cysts and lumps, nipple discharge and breast cancer); K -Performs assessment, formulates differential diagnosis and provides initial treatment in common benign breast disorders (cyclic and noncyclic breast pain, fibrocystic breast changes, cysts and lumps, nipple discharge and breast cancer); K / S -Identifies women with breast cancer risk factors in primary care settings by using clinical information and breast cancer (BC) risk assessment models, and provides a care plan for follow-up these patients;

R1
-Demonstrates knowledge of the common non-reproductive medical disorders related to the reproductive system (hypertension, diabetes, dyslipidemia, metabolic syndrome, obesity, anorexia, depression, osteoporosis, lupus, thyroid dysfunction, HIV infection); K -Performs anamnesis, physical examination, differential diagnosis and appropriately request the exams and procedures for the initial diagnostic approach; K / S R2 -Interprets test results for the disorders described above; K / S -Preliminary manages the therapeutic plans for patients with common non-reproductive medical disorders (hypertension, diabetes, thyroid dysfunction); K / S / A R3 -Preliminary manages the therapeutic plans for patients with complex non-reproductive medical disorders (osteoporosis, metabolic syndrome, eating disorders, HIV infection);
Rev Bras Ginecol Obstet Vol. 42 No. 5/2020 Box 16 Professionalism in gynecology and obstetrics General goal: acquisition of competencies related to professionalism in Gynecology and Obstetrics.

R1
-Shows respect and interest in patients as human beings, regardless of their sexual choice, sex, religion, race/color, and social class; A -Communicates effectively with patients, family members, caregivers and work team members and does not use derogatory or aggressive language; S / A -Promotes qualified listening without prejudice and discusses the care plan with the patient and the work team;