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Original Investigation | Association of VA Surgeons

Identifying and Eliminating Deficiencies in the General Surgery Resident Core Competency Curriculum FREE

Nicole M. Tapia, MD1; Allen Milewicz, MD, MBA1; Stephen E. Whitney, MD, MBA2; Michael K. Liang, MD1,3; Carla C. Braxton, MD, MBA1
[+] Author Affiliations
1Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2Department of Pediatrics, Baylor College of Medicine, Houston, Texas
3currently with The University of Texas Health Sciences Center at Houston
JAMA Surg. 2014;149(6):514-518. doi:10.1001/jamasurg.2013.4406.
Text Size: A A A
Published online

Importance  Although the Accreditation Council for Graduate Medical Education has defined 6 core competencies required of resident education, no consensus exists on best practices for reaching resident proficiency. Surgery programs must develop resourceful methods to incorporate learning. While patient care and medical knowledge are approached with formal didactics and traditional Halstedian educational formats, other core competencies are presumed to be learned on the job or emphasized in conferences.

Objectives  To test the hypothesis that our residents lack a foundation in several of the nonclinical core competencies and to seek to develop a formal curriculum that can be integrated into our current didactic time, with minimal effect on resident work hours and rest hours.

Design, Setting, and Participants  Anonymous Likert-type scale needs assessment survey requesting residents within a large single general surgery residency program to rate their understanding, working knowledge, or level of comfort on the following 10 topics: negotiation and conflict resolution; leadership styles; health care legislation; principles of quality delivery of care, patient safety, and performance improvement; business of medicine; clinical practice models; role of advocacy in health care policy and government; personal finance management; team building; and roles of innovation and technology in health care delivery.

Main Outcomes and Measures  Proportions of resident responses scored as positive (agree or strongly agree) or negative (disagree or strongly disagree).

Results  In total, 48 surgery residents (70%) responded to the survey. Only 3 topics (leadership styles, team building, and roles of innovation and technology in health care delivery) had greater than 70% positive responses, while 2 topics (negotiation and conflict resolution and principles of quality delivery of care, patient safety, and performance improvement) had greater than 60% positive responses. The remaining topics had less than 40% positive responses, with the least positive responses on the topics business of medicine (13% [6 of 48]) and health care legislation (19% [9 of 48]).

Conclusions and Relevance  General surgery residents in our program do not report being knowledgeable or comfortable with several areas of the nonclinical Accreditation Council for Graduate Medical Education core competencies. We developed a formal health care policy and management curriculum, with integration into preexisting protected surgical didactic time. This curriculum fulfills educational requirements, without negatively affecting resident work hours and without increased expense to the department of surgery. Future studies measuring the effect of this integrated program on resident education, knowledge, and satisfaction are warranted.

Figures in this Article

Acknowledging that the practice of medicine requires more than mastery of medical knowledge, in 1999 the Accreditation Council for Graduate Medical Education (ACGME) developed a core competency framework for integration into current residency education,1 with the goal of producing safe, competent physicians with a thorough understanding of a complex medical environment. Specifically, the 6 competencies defined as core components of resident education include patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Although residency programs were charged with the task of incorporating the nonclinical core competencies into their curriculum, no consensus exists as to how to best fulfill the requirement.

Consequently, residency programs have used multiple techniques to integrate the core competencies into the learning process. These include rigorous morbidity and mortality conferences,2 morning report,3 self-directed learning,4,5 web-based modules,4,6 and classic on-the-job Halstedian teaching.7 Patient care and medical knowledge are arguably the most facile to incorporate and test: didactic learning programs such as the Surgical Council on Resident Education8 curriculum are universally used in many residency programs, and surgical knowledge is annually tested with the American Board of Surgery In-Training Examination.9 However, other topics such as practice-based learning and improvement, interpersonal and communication skills, systems-based practice, and even professionalism are broad in scope and more difficult to structure into a curriculum. Surgical faculty may lack the expertise to competently teach such topics.10 Many programs have created an additional track for residents interested in health care policy, which frequently adds 6 months to 1 year to the resident’s term of training. Other programs have partnered with a master of public health, public policy administration, or business administration program to allow the resident to earn an additional degree during residency. We developed our curriculum following compelling recommendations of a group of resident authors, who suggested that health care policy education may best be integrated into overall surgical resident education.1113 The integration would alleviate the need for prolonging residency training or for obtaining an additional degree. This approach would also allow all of the residents to benefit from the information shared, not just residents who would have been willing to add time to their training. We took this recommendation a step further in that the work group realized that health policy education alone was inadequate to fulfill ACGME requirements and that residents could benefit from instruction in broader topics, including leadership and management.

Our residency program uses many of the techniques described, but we hypothesized that our residents are not comfortable with several of the core competencies. An ideal solution would be the development of a formal curriculum that integrates with current didactic time, minimizing the effect on resident work hours and rest hours.

Institutional review board approval was not required for the study. Surveys were anonymous, with deidentified data. Oral informed consent was obtained from the participants, and they could decline to participate by simply not completing the survey. The health care policy and management curriculum began as an attempt to fulfill an educational requirement for the surgery residency during the course of a completely new rendering of the larger surgical education curriculum. We used established methods for curriculum development14 and included taxonomy terms for cognitive, affective, and psychomotor outcomes. Understanding that the course was going to be an established part of the residency program and had specific components that were compulsory, we created the foundational content of the curriculum without resident involvement. After the primary course content was established, we developed a 10-question survey in which our general surgery residents were asked to rate their understanding, working knowledge, or level of comfort on the following topics: (1) negotiation and conflict resolution; (2) leadership styles; (3) health care legislation; (4) principles of quality delivery of care, patient safety, and performance improvement; (5) business of medicine, including management principles, contract language, and insurance concepts; (6) clinical practice models; (7) role of advocacy in health care policy and government; (8) personal finance management; (9) team building; and (10) roles of innovation and technology in health care delivery (Figure 1). Responses were scored as positive (agree or strongly agree) or negative (disagree or strongly disagree). Surveys were distributed in September 2012 during grand rounds, protected didactic time for our residents, such that survey completion would be robust.

Place holder to copy figure label and caption
Figure 1.
Self-assessment Survey of ACGME Competency Knowledge

ACGME indicates Accreditation Council for Graduate Medical Education.

Graphic Jump Location

Concurrently, a work group composed of surgeons and pediatricians with MBA degrees and experience with curriculum development, as well as surgery resident representatives, met to establish a health care policy and management curriculum. The collaboration among clinical and academic faculty, department administration, and surgery residents sought to create a curriculum that fulfills ACGME requirements for resident education in professionalism, systems-based practice, interpersonal and communication skills, and practice-based learning and improvement. This was accomplished by organizing into the health care policy and management curriculum the study of policy, management, and leadership in health care, with a focus on skill sets needed for the current health care climate. The health care policy and management curriculum was presented to the department of surgery education committee for approval and implementation.

The survey response rate among the residents was 70%, with 48 residents completing the survey. Responses were equally distributed among all resident levels and included categorical and noncategorical general surgery residents, as well as categorical subspecialty surgical residents who were interns in the department of surgery. Results were not stratified based on level of training. The residents rated themselves positively (>70% positive response) on the following 3 topics: leadership styles, team building, and roles of innovation and technology in health care delivery. Negotiation and conflict resolution and principles of quality delivery of care, patient safety, and performance improvement each had greater than 60% positive responses. The remaining topics had less than 40% positive responses. The least positive responses were on the topics of business of medicine (13% [6 of 48]) and health care legislation (19% [9 of 48]) (Table).

Table Graphic Jump LocationTable.  Responses to Self-assessment Survey of ACGME Competency Knowledge Among 48 Surgery Residents

Using ACGME descriptions of the core competencies, the health care policy and management curriculum work group defined 9 resident learning objectives (Figure 2) that would fulfill ACGME requirements, with 3 areas of focus. The 3 major areas are: (1) health care systems and policy, (2) management and clinical practice, and (3) leadership. Figure 3 shows subtopics within each major area of focus. The work group’s primary constraint was that any new curriculum had to be implementable within the current didactic weekly schedule, which includes 1 hour of grand rounds, followed by 1 hour of small group didactic learning. A 2-year rotating curriculum was defined within these parameters. With permission of the department of surgery education committee, 10 hours of dedicated time were allotted per year. Professionalism, systems-based practice, interpersonal and communication skills, and practice-based learning and improvement are covered at least once each year within the 2-year rotation. The rich resources of the Houston metropolitan area and Texas Medical Center allowed the creation of a lecture schedule of experts in health policy and legislation, law, organization management, surgical ethics, contracts, advocacy, technology, and communication. Surgery faculty were included if they had special interest or extensive publication in surgical quality, safety, practice specifics, and process improvement. Lecturers were encouraged to present their material in an interactive fashion using multimedia and case studies when appropriate.

Place holder to copy figure label and caption
Figure 2.
Resident Learning Objectives

The health care policy and management curriculum work group defined 9 resident learning objectives.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Health Care Policy and Management Curriculum

Major and minor topics.

Graphic Jump Location

The curriculum was implemented in mid-September 2012, shortly after the resident survey. Because the health care policy and management curriculum is part of the overall surgical education experience, some of the expert presentations took place during grand rounds and others during a time designated for a more dynamic resident small group session. Topics covered in the inaugural year of the new curriculum included professionalism, staff management, interpersonal skills in clinical practice, liability reduction in surgery (with liability case reviews), health care legislation and policy development, marketing in medicine, ethical dilemmas in surgery, importance of physician advocacy, innovation in surgery, and financial management. The second year of the 2-year cycle will include topics not covered in the prior year but may necessarily have some overlap because of the breadth of discussion that is innate to health care policy, management, and leadership.

The ACGME core competencies are a necessary, albeit challenging, addition to the already substantial surgery curriculum. With reduction of work hours, surgery residents and faculty already perceive that residents’ technical training is at risk, with fewer operative cases,1518 and that patient continuity and coordination of patient care will suffer.19 The addition of laparoscopic skills certification20 and endoscopy case requirements21 further reduces time for the inclusion of the core competencies. While it may be tempting and appealing to use current conferences such as morning report3 and morbidity and mortality2 as an aid for teaching these core competencies, we have found that residents perceive these current methods are insufficient to develop an adequate knowledge base or skill set.

Our goal was to develop a curriculum that would not require time from the residents’ clinical or personal schedules but would be comprehensive enough to fulfill ACGME requirements, plus create a foundation for further learning in leadership, health care management, and legislation. The inclusion of competency training into current didactic time, protected learning time for our residents, is a cornerstone of our plan and could be used by even smaller surgery programs that face greater challenges when dealing with duty hour restrictions.22

By taking advantage of neighboring universities, graduate schools, Fortune 500 companies, and our own faculty institutional expertise, we can provide stimulating speakers from our local academic and business communities. We were able to strengthen our competency curriculum at no additional cost to the department of surgery. Invited speakers were flattered and delighted to be included in our discussions and volunteered their time and expertise. By identifying regional speakers, repeat participation in coming years should be feasible. This use of local resources can potentially be repeated at other residency programs, even those that are within a community and not attached specifically to an academic institution. Residents and faculty enthusiastically received the novel and thought-provoking additions to the curriculum.

Although the introduction of this curriculum into our didactic learning experience has been a positive initial step in integrating nonclinical topics into surgical residency education, we recognize that more rigorous studies of its effect on resident education, knowledge, and satisfaction are a necessary function of the final step of curriculum development.23 Future evaluations may include pretesting the residents to determine if their perceived deficiencies matched actual lack of knowledge. A criticism of this study may be that we did not stratify the survey based on resident level; however, this would have made the response numbers too small to gain anything but anecdotal information. Future surveys with stratification will be confounded by the current existence of a focused health care policy and management education and may not provide accurate information regarding deficits in resident education. Our institution has recently hired a PhD educator (May 2013), who will be able to assist us in further development of this curriculum. Ideally, precurriculum and postcurriculum testing of knowledge within each curricular element, as well as satisfaction surveys, should be implemented, starting with our 2013 intern class and stratified by year to follow accumulation and retention of competency knowledge. Resident feedback is essential for improvement of the curriculum. Becoming an expert in any of the core competencies will require further postgraduate training. Our goal is for our residents to obtain a fundamental knowledge base through this integrated longitudinal curriculum, conveying the idea that competency can be achieved without earning additional degrees or certificates.

We have developed a formal health care policy and management curriculum that is fully integrated into the surgical education program using existing protected didactic time for residents. This curriculum helps fulfill the ACGME core competency requirements, without affecting resident work hours or rest hours, with no requirement of additional degrees or certificates, and at no cost to the department of surgery for this enhancement to surgery resident education. This curricular addition may serve as a template for other surgical residencies to integrate educational content with minimal resident and department expenditure. Future studies measuring the effect of the program are warranted.

Accepted for Publication: July 15, 2013.

Corresponding Author: Nicole M. Tapia, MD, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Ste 404D, Houston, TX 77030 (nmtapia@bcm.edu).

Published Online: April 2, 2014. doi:10.1001/jamasurg.2013.4406.

Author Contributions: Drs Tapia and Braxton had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Tapia, Braxton.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Tapia.

Study supervision: Braxton.

Conflict of Interest Disclosures: None reported.

Disclaimer: The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official view of the Baylor College of Medicine, the Michael E. DeBakey Department of Surgery, or the Baylor Department of Pediatrics.

Previous Presentation: This study was presented at the 2013 Association of VA Surgeons annual meeting; April 21, 2013; Milwaukee, Wisconsin.

ACGME program requirements for graduate medical education in general surgery. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/440_general_surgery_01012008_07012012.pdf. Accessed April 5, 2013.
Kauffmann  RM, Landman  MP, Shelton  J,  et al.  The use of a multidisciplinary morbidity and mortality conference to incorporate ACGME general competencies. J Surg Educ. 2011;68(4):303-308.
PubMed   |  Link to Article
Stiles  BM, Reece  TB, Hedrick  TL,  et al.  General surgery morning report: a competency-based conference that enhances patient care and resident education. Curr Surg. 2006;63(6):385-390.
PubMed   |  Link to Article
Mitchell  JD, Parhar  P, Narayana  A.  Teaching and assessing systems-based practice: a pilot course in health care policy, finance, and law for radiation oncology residents. J Grad Med Educ. 2010;2(3):384-388.
PubMed   |  Link to Article
Peters  AS, Kimura  J, Ladden  MD, March  E, Moore  GT.  A self-instructional model to teach systems-based practice and practice-based learning and improvement. J Gen Intern Med. 2008;23(7):931-936.
PubMed   |  Link to Article
Whitson  BA, Hoang  CD, Jie  T, Maddaus  MA.  Technology-enhanced interactive surgical education. J Surg Res. 2006;136(1):13-18.
PubMed   |  Link to Article
Assael  LA.  Every surgeon needs mentors: a Halsteadian/Socratic model in the modern age. J Oral Maxillofac Surg. 2010;68(6):1217-1218.
PubMed   |  Link to Article
Bell  RH.  Surgical Council on Resident Education: a new organization devoted to graduate surgical education. J Am Coll Surg. 2007;204(3):341-346.
PubMed   |  Link to Article
ABS In-Training Examination (ABSITE). http://www.absurgery.org/default.jsp?certabsite. Accessed April 5, 2013.
Harris  EE, Abdel-Wahab  M, Spangler  AE, Lawton  CA, Amdur  RJ.  Results of the Association of Directors of Radiation Oncology Programs (ADROP) survey of radiation oncology residency program directors. Int J Radiat Oncol Biol Phys. 2009;74(2):327-337.
PubMed   |  Link to Article
Buck  DW  II, Bittner  JG  IV, Hayanga  JA, Powell  AC.  Preparing surgeons for a seat at the health care policy table: a proposal for a longitudinal health care policy curriculum during surgical training. Bull Am Coll Surg. 2010;95(7):21-26.
PubMed
Greysen  SR, Wassermann  T, Payne  P, Mullan  F.  Teaching health policy to residents: three-year experience with a multi-specialty curriculum. J Gen Intern Med. 2009;24(12):1322-1326.
PubMed   |  Link to Article
Patel  MS, Davis  MM, Lypson  ML.  Advancing medical education by teaching health policy. N Engl J Med. 2011;364(8):695-697.
PubMed   |  Link to Article
Thomas  PA, Kern  DE.  Internet resources for curriculum development in medical education: an annotated bibliography. J Gen Intern Med. 2004;19(5, pt 2):599-605.
PubMed   |  Link to Article
Damadi  A, Davis  AT, Saxe  A, Apelgren  K.  ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency. J Surg Educ. 2007;64(5):256-259.
PubMed   |  Link to Article
Weatherby  BA, Rudd  JN, Ervin  TB, Stafford  PR, Norris  BL.  The effect of resident work hour regulations on orthopaedic surgical education. J Surg Orthop Adv. 2007;16(1):19-22.
PubMed
Carlin  AM, Gasevic  E, Shepard  AD.  Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg. 2007;193(3):326-330.
PubMed   |  Link to Article
Kairys  JC, McGuire  K, Crawford  AG, Yeo  CJ.  Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg. 2008;206(5):804-813.
PubMed   |  Link to Article
Antiel  RM, Van Arendonk  KJ, Reed  DA,  et al.  Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors. Arch Surg. 2012;147(6):536-541.
PubMed   |  Link to Article
Castellvi  AO, Hollett  LA, Minhajuddin  A, Hogg  DC, Tesfay  ST, Scott  DJ.  Maintaining proficiency after fundamentals of laparoscopic surgery training: a 1-year analysis of skill retention for surgery residents. Surgery. 2009;146(2):387-393.
PubMed   |  Link to Article
Subhas  G, Gupta  A, Mittal  VK.  Necessity for improvement in endoscopy training during surgical residency. Am J Surg. 2010;199(3):331-335.
PubMed   |  Link to Article
Antiel  RM, Thompson  SM, Hafferty  FW,  et al.  Duty hour recommendations and implications for meeting the ACGME core competencies: views of residency directors. Mayo Clin Proc.2011;86(3):185-191.
PubMed   |  Link to Article
Kern  DE, Thomas  PA, Howard  DM, Bass  EB. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: Johns Hopkins Press; 1998.

Figures

Place holder to copy figure label and caption
Figure 1.
Self-assessment Survey of ACGME Competency Knowledge

ACGME indicates Accreditation Council for Graduate Medical Education.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Resident Learning Objectives

The health care policy and management curriculum work group defined 9 resident learning objectives.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Health Care Policy and Management Curriculum

Major and minor topics.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Responses to Self-assessment Survey of ACGME Competency Knowledge Among 48 Surgery Residents

References

ACGME program requirements for graduate medical education in general surgery. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/440_general_surgery_01012008_07012012.pdf. Accessed April 5, 2013.
Kauffmann  RM, Landman  MP, Shelton  J,  et al.  The use of a multidisciplinary morbidity and mortality conference to incorporate ACGME general competencies. J Surg Educ. 2011;68(4):303-308.
PubMed   |  Link to Article
Stiles  BM, Reece  TB, Hedrick  TL,  et al.  General surgery morning report: a competency-based conference that enhances patient care and resident education. Curr Surg. 2006;63(6):385-390.
PubMed   |  Link to Article
Mitchell  JD, Parhar  P, Narayana  A.  Teaching and assessing systems-based practice: a pilot course in health care policy, finance, and law for radiation oncology residents. J Grad Med Educ. 2010;2(3):384-388.
PubMed   |  Link to Article
Peters  AS, Kimura  J, Ladden  MD, March  E, Moore  GT.  A self-instructional model to teach systems-based practice and practice-based learning and improvement. J Gen Intern Med. 2008;23(7):931-936.
PubMed   |  Link to Article
Whitson  BA, Hoang  CD, Jie  T, Maddaus  MA.  Technology-enhanced interactive surgical education. J Surg Res. 2006;136(1):13-18.
PubMed   |  Link to Article
Assael  LA.  Every surgeon needs mentors: a Halsteadian/Socratic model in the modern age. J Oral Maxillofac Surg. 2010;68(6):1217-1218.
PubMed   |  Link to Article
Bell  RH.  Surgical Council on Resident Education: a new organization devoted to graduate surgical education. J Am Coll Surg. 2007;204(3):341-346.
PubMed   |  Link to Article
ABS In-Training Examination (ABSITE). http://www.absurgery.org/default.jsp?certabsite. Accessed April 5, 2013.
Harris  EE, Abdel-Wahab  M, Spangler  AE, Lawton  CA, Amdur  RJ.  Results of the Association of Directors of Radiation Oncology Programs (ADROP) survey of radiation oncology residency program directors. Int J Radiat Oncol Biol Phys. 2009;74(2):327-337.
PubMed   |  Link to Article
Buck  DW  II, Bittner  JG  IV, Hayanga  JA, Powell  AC.  Preparing surgeons for a seat at the health care policy table: a proposal for a longitudinal health care policy curriculum during surgical training. Bull Am Coll Surg. 2010;95(7):21-26.
PubMed
Greysen  SR, Wassermann  T, Payne  P, Mullan  F.  Teaching health policy to residents: three-year experience with a multi-specialty curriculum. J Gen Intern Med. 2009;24(12):1322-1326.
PubMed   |  Link to Article
Patel  MS, Davis  MM, Lypson  ML.  Advancing medical education by teaching health policy. N Engl J Med. 2011;364(8):695-697.
PubMed   |  Link to Article
Thomas  PA, Kern  DE.  Internet resources for curriculum development in medical education: an annotated bibliography. J Gen Intern Med. 2004;19(5, pt 2):599-605.
PubMed   |  Link to Article
Damadi  A, Davis  AT, Saxe  A, Apelgren  K.  ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency. J Surg Educ. 2007;64(5):256-259.
PubMed   |  Link to Article
Weatherby  BA, Rudd  JN, Ervin  TB, Stafford  PR, Norris  BL.  The effect of resident work hour regulations on orthopaedic surgical education. J Surg Orthop Adv. 2007;16(1):19-22.
PubMed
Carlin  AM, Gasevic  E, Shepard  AD.  Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg. 2007;193(3):326-330.
PubMed   |  Link to Article
Kairys  JC, McGuire  K, Crawford  AG, Yeo  CJ.  Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg. 2008;206(5):804-813.
PubMed   |  Link to Article
Antiel  RM, Van Arendonk  KJ, Reed  DA,  et al.  Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors. Arch Surg. 2012;147(6):536-541.
PubMed   |  Link to Article
Castellvi  AO, Hollett  LA, Minhajuddin  A, Hogg  DC, Tesfay  ST, Scott  DJ.  Maintaining proficiency after fundamentals of laparoscopic surgery training: a 1-year analysis of skill retention for surgery residents. Surgery. 2009;146(2):387-393.
PubMed   |  Link to Article
Subhas  G, Gupta  A, Mittal  VK.  Necessity for improvement in endoscopy training during surgical residency. Am J Surg. 2010;199(3):331-335.
PubMed   |  Link to Article
Antiel  RM, Thompson  SM, Hafferty  FW,  et al.  Duty hour recommendations and implications for meeting the ACGME core competencies: views of residency directors. Mayo Clin Proc.2011;86(3):185-191.
PubMed   |  Link to Article
Kern  DE, Thomas  PA, Howard  DM, Bass  EB. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: Johns Hopkins Press; 1998.

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