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Review and Special Articles

Defining Competencies and Performance


Indicators for Physicians in Medical Management
Dorothy S. Lane, MD, MPH, Virginia Ross, PhD

ABSTRACT The recent and profound changes in the American health care delivery system have
created a need for physicians who are trained and willing to assume a high level of
responsibility for managing evolving health care organizations. Yet most physicians receive
no formal training in medical administration and management because changes in
medical school and residency education have lagged behind changes in clinical practice
and reimbursement. To avoid haphazard approaches and unnecessary duplication of
resources, it is important for physicians involved in managerial medicine to collectively
identify competencies in this area needed in the marketplace. The American College of
Preventive Medicine (ACPM), with funding from the Health Resources and Services
Administration (HRSA), undertook an effort to identify competencies essential for
physicians who will fill leadership roles in medical management. Like ACPM’s earlier effort
to develop core competencies in preventive medicine, this project drew upon the
theoretical model of competency-based education. This article describes the strategy we
followed in reaching consensus among a diverse group of physician executives and
preventive medicine residency program directors, and includes the list of medical
management competencies and performance indicators developed. Recurrent issues that
can sidetrack competency development projects are also presented as well as suggestions
for overcoming them. The competencies can serve as a framework for expanding current
core preventive medicine training in management and administration and for developing
new training programs to equip physicians with the special expertise they will need to
provide management leadership within the changing landscape of health care delivery.
Medical Subject Headings (MeSH): competency-based education, preventive medicine,
organization and administration. (Am J Prev Med 1998;14:229 –236) © 1998 American
Journal of Preventive Medicine

Introduction institutions, and patients. Decisions about the use of


technology are challenged by regulators, insurers, and

T
he recent and profound changes in the Ameri-
ethicists. In this increasingly complex arena, there is an
can health care delivery and reimbursement
urgent need for physicians with expertise in medical
systems have created a need for physicians who
are trained and willing to assume a high level of management.
responsibility for managing evolving health care orga- Yet most physicians receive no formal preparation in
nizations. Physician leadership is critical for attaining the management of health care services and systems.
balance among conflicting pressures for quality of care Changes in medical school and residency education
versus cost containment, prevention versus high-tech- have lagged behind the changes in the landscape of
nology medical intervention, and application of special- clinical practice and reimbursement. A survey con-
ized versus primary care. Physicians must be involved in ducted more than a decade ago revealed that more
resource allocation because of their knowledge of the than 80% of physicians who work in administrative
clinical implications of management decisions. Individ- positions believe that formal management training
ual physicians’ decisions about medical care are now should either be required (22%) or is advisable (62%)
challenged by third-party payers, lawyers, legislators, for physician administrators.1 The authors concluded
that integrating management principles in a medical
context is the best way to provide this training, which
From the Department of Preventive Medicine, School of Medicine, State
University of New York at Stony Brook, (Lane) Stony Brook, New York, they predicted will become even more important in the
USA 11794-8036. (Ross) 116 Garden Lane, Decatur, Georgia 30030. future. Recent surveys of both young physicians and
Address correspondence to Dorothy S. Lane, MD, MPH, Depart-
ment of Preventive Medicine, School of Medicine, HSC 3-086, State
health management organization (HMO) administra-
University of New York at Stony Brook, Stony Brook, NY 11794-8036. tors have concluded that medical training is not ade-

Am J Prev Med 1998;14(3) 0749-3797/98/$19.00 229


© 1998 American Journal of Preventive Medicine PII S0749-3797(97)00068-8
quately preparing physicians for the current realities of fined population needs, to design and implement
medical practice, leading to calls for changes in medi- programs to promote health and prevent disease within
cal education to better prepare physicians for a practice medical practice settings, to perform health services
environment dominated by managed care.2 and outcomes research leading to evidence-based prac-
The rising financial pressures to contain cost have tice and cost-effective decisions, and to make manage-
also led to an increased emphasis on evaluation of the ment decisions affecting patient care that are based on
performance of physicians. A nation that spends 13.6% clinical and medical knowledge as well as administrative
of its resources on health care demands that quality of and fiscal considerations.
services be examined.3 The era of lifetime certification A 1991 survey conducted by the Battelle Memorial
has given way to requirements for periodic recertifica- Institute under contract with the U.S. Centers for
tion and performance assessment. Many recent studies Disease Control and Prevention (CDC) and the Health
have attempted to assess a link between specialty board Resources and Services Administration (HRSA) found
certification and clinical outcomes and to explore that administration and management activities com-
methods to evaluate the performance of physicians, prised the largest single practice area reported by
including peer assessment, self-assessment, and assess- preventive medicine physicians, occupying at least one
ment by patients or nursing staff.4 third of their time. Most respondents expressed a
To avoid haphazard approaches as well as unneces- desire to have more focused and extensive manage-
sary duplication of resources and to ensure an appro- ment training and experience to prepare them for
priate basis for evaluating effective delivery of health positions in which they practice.5 These results led to
services, it is important for physicians who are involved increased attention by preventive medicine residency
in medical management and those in academia to program directors to the competencies their graduates
collectively identify the competencies in this area that will need in the area of medical management. Respond-
are needed in the marketplace. Residency training ing to the current and projected need for medical
programs can then be put in place to train physicians to practitioners with these competencies, the ABPM has
provide medical management leadership and to edu- submitted a proposal to the American Board of Medical
cate future medical students and other residents in the Specialties (ABMS) for approval to certify physicians in
skills they will need in future employment. the subspecialty of Managerial Medicine. This subspe-
The field of preventive medicine has made an effort cialty certificate would be open to qualified diplomates
in this direction because of the specialty’s integral of all ABMS member boards. In developing the pro-
connection with medical management and because of posal, the ABPM has worked collaboratively with the
prior experience in identifying physician competen- American Board of Medical Management (ABMM), a
cies. Management and administration have always been non-ABMS board, chartered by the American College
major core components of all the specialty areas of of Physician Executives (ACPE), which no longer ad-
preventive medicine (aerospace medicine, general pre- ministers certifying examinations.
ventive medicine and public health, occupational med-
icine) and a primary content area of the American
Background
Board of Preventive Medicine (ABPM) certifying exam-
ination since it began certifying qualified physicians in The American College of Preventive Medicine
the specialty 50 years ago. The field of preventive (ACPM), the specialty society of preventive medicine
medicine provides a necessary bridge between the physicians, has had a long history of developing com-
disciplines that need to work together in evolving petencies that apply to all trainees of preventive medi-
health care systems. In integrated health systems, phy- cine residencies in the three specialty areas that are
sicians are responsible for the health of a population, part of the discipline. These competencies were in-
not just for individual patients. Improving the health of tended to help structure field assignments, achieve
a population requires knowledge of epidemiology to agreement in the expectations of residents and faculty,
determine the population’s health status, risks, and assess residents’ progress, provide opportunities for
needs; team-building skills to coordinate community residents to assess their own needs or gaps in training
interventions; and knowledge of preventive care and or experience, and identify the expertise of graduates
health promotion to prevent disease. As the nation to potential employers and funding sources.6 – 8
moves toward a health system based on prevention and Meetings of the ACPM Graduate Medical Education
primary care, with different organizational arrange- Subcommittee were held twice each year in conjunc-
ments and systems linkages, physicians with skills in tion with national professional meetings. “Competency
population-based medicine and health care organiza- workshops” were sponsored at these meetings and were
tion management are critical. targeted toward residency directors and faculty, resi-
Preventive medicine physicians have the skills and dents, and preventive medicine practitioners to pro-
competencies needed to evaluate community and de- mote common understanding of terms and approaches

230 American Journal of Preventive Medicine, Volume 14, Number 3


to developing definitions of competencies and to share theoretical model of competency-based education
program experiences. The ACPM subcommittee chair (CBE).9 –13 CBE is a form of education that derives a
and an educational consultant structured working ses- curriculum from an analysis of a prospective or actual
sions at subcommittee meetings during which the lists professional role and then attempts to certify student
of core competencies were drafted. Drafts were subse- progress on the basis of demonstrated performance in
quently mailed for comment to all residency program some aspects of that role. CBE requires that outcomes
directors and to members of the ACPM Board of of instruction are observable and measurable. Evalua-
Regents, the Residency Review Committee for Preven- tion is directly linked to the behavior specified in a
tive Medicine, the ABPM, and other interested individ- particular competency definition.
uals and groups. This method of development elicited Principles from the field of CBE coincide with con-
wide participation and encouraged broad-based con- clusions of research specific to residency training. Re-
sensus. search results show that residents should be told what is
To further the competency development process, the expected of them and exactly how they will be evalu-
Bureau of Health Professions of HRSA provided funds ated. In addition, they should be provided with feed-
through a contract with the preventive medicine resi- back about their performance on a regular basis.14
dency program at the State University of New York For the purposes of defining medical management
(SUNY) at Stony Brook to work with the ACPM on competencies, ACPM used as a working definition of
developing performance indicators to measure the competency the ability to perform a complex task or
accomplishment of each of the core competencies and function. In addition to ensuring the ability to perform
to begin to define competencies for the three specialty work roles to standards expected in real employment
areas within preventive medicine. A work group of situations, competency implies an ability to transfer
program directors was convened, representing all spe- skills and knowledge to new situations. Competency
cialty areas and types of sponsoring institutions (health pertains not only to subject matter but also to proce-
department, medical school, school of public health). dural knowledge and judgment. The following charac-
Needed continuity was provided by overlapping mem- teristics of competencies guided the development pro-
bership on the HRSA work group and the ACPM cess: they describe outcomes expected from the
committee and by the involvement of the committee performance of professionally related functions; they
chair and the project consultant in both phases of are treated as tentative predictors of professional per-
competency development. The final document was formance; and they are made available to the trainee
approved by the ACPM Board of Regents and dissemi- before the training begins. Although they should be
nated by the ACPM and HRSA in 1994. stated as precisely as possible, they also should be at a
Many residencies have integrated the ACPM compe- level of generality that has importance as well as
tency definitions into the operation of their individual meaning to the trainee.
training programs. Several use them for the purpose of Because they are complex, competencies are not easy
evaluating resident performance by incorporating to describe precisely or evaluate accurately. Whenever
them into a grid that permits supervisors to document possible, evaluation should be linked to specific perfor-
competency achievement and how and where this was mance indicators. Performance indicators are categories
accomplished. The competencies have been incorpo- of evidence to be used as a basis for judging compe-
rated into affiliation agreements between the sponsor- tency attainment, or criteria that can be used to distin-
ing and participating institutions, thereby meeting the guish competent from incompetent performance.
Accreditation Council for Graduate Medical Education With funding from a contract with HRSA, which was
(ACGME) requirement for definition of the educa- designed to update the existing competencies in pre-
tional objectives of the affiliation experience. The ventive medicine, the ACPM formed a work group on
specificity provided by the competency definitions has medical management competencies, comprised of phy-
proved particularly useful at rotation sites where resi- sician executives and preventive medicine residency
dents had not previously been assigned since they guide program directors with expertise in medical manage-
the faculty in structuring appropriate learning oppor- ment. The 13 members of the work group were selected
tunities. to include twice as many practitioners or employers as
academicians (see Appendix). The ACPM convened a
two-day meeting of the work group in December 1996.
Strategy
Working from a preliminary draft of competencies
Based on the experience in developing core and spe- prepared by the ACPM Education Committee with
cialty area competencies for preventive medicine resi- input from preventive medicine residency program
dents, the ACPM undertook the process of defining directors, the work group developed a list of medical
competencies in medical management. This develop- management competencies and performance indica-
ment process, like the earlier effort, drew upon the tors for physicians taking additional specialized train-

Am J Prev Med 1998;14(3) 231


Table 1. Verbs to consider in formulating competenciesa

These verbs are better avoided:


Appreciate Believe Know Learn Understand
These verbs were found to be useful in formulating competencies:
Analyze Apply Appraise Assess Assure
Characterize Classify Communicate Compare Compose
Conduct Construct Coordinate Create Critique
Deduce Demonstrate Describe Design Detect
Determine Develop Diagnose Diagram Differentiate
Distinguish Document Estimate Evaluate Examine
Explain Formulate Identify Illustrate Implement
Indicate Integrate Interpret Manage Measure
Modify Operate Order Organize Plan
Practice Predict Prepare Prescribe Produce
Propose Rank Rate Recommend Refine
Relate Report Review Select Separate
Specify Summarize Test Translate Transfer
Treat Use Utilize Validate Write
a
Adapted from reference.15

ing in this field of practice. In addition, the work group ments that suggested additional detail for the same
reviewed and updated the existing core preventive performance indicator, on the other. This dichotomy
medicine competencies in management and adminis- particularly applied to areas relating to financial man-
tration for residents of all preventive medicine resi- agement and evidence of leadership abilities. Through
dency training programs. discussion and additional written feedback to reach
The results of the working session were discussed at consensus, the work group agreed on the revised final
the Annual Workshop of Preventive Medicine Resi- version presented below in Results.
dency Program Directors held later that month and in In the competency development sessions, providing
various forums held in conjunction with the national committees with lists of possible verbs useful for formu-
Prevention ’97 conference. In addition, the medical lating competencies facilitated the development pro-
management competencies and related updated man- cess. A suggested list of verbs is displayed in Table 1.
agement and administration core competencies were Our experience also led us to identify several recurring
mailed for comment to a broad audience of interested tendencies that can potentially sidetrack the process of
parties: preventive medicine residency program direc- competency development by a committee, as illustrated
tors in all three specialty areas; members of the Board in Table 2.
of Regents of the ACPM; members of the ABPM;
members of the Residency Review Committee (RRC)
Results
for Preventive Medicine of the ACGME; members of
the Board of Directors of both the ABMM and the
Medical Management Competencies
ACPE; and other individuals interested in training in Delivery of Health Care
medical management. Numerous comments were re-
1. Design, manage, and evaluate health service delivery
ceived on the draft. While virtually all included positive
programs to improve the health of a defined popu-
remarks and appreciation for the work that was being
lation.
done, a few respondents expressed a particular con-
cern. The concerns noted were: the feasibility of devis- This reflects demonstrated ability in:
ing managerial experience in which residents can ac- a. planning and implementation of strategies for
complish these competencies during training; the health promotion, disease prevention, demand
status of medical management as a legitimate medical management (self-care), and disease management
field; whether preventive medicine should embrace in a health care organization.
medical management as a primary, separate branch b. design, implementation, and evaluation of clinical
within the field and whether the competencies are the practice guidelines, quality management/quality im-
exclusive domain of preventive medicine. A particular provement programs, utilization management, case
challenge in finalizing the competencies and perfor- management, and other activities to enhance an
mance indicators involved balancing comments that organization’s performance and reduce practice
residents could not be expected to master a particular variation.
performance indicator, on the one hand, versus com- c. evaluation of health service delivery through appli-

232 American Journal of Preventive Medicine, Volume 14, Number 3


Table 2. Recurring tendencies to overcome in competency development projects

z Groups accustomed to designing curriculum tend to think in terms of knowledge rather than skills. Looking at knowledge
only makes measurement of competence difficult. (For instance, “Understand factors affecting patient compliance.”)
z An effort to make competencies as precise and measurable as possible can lead a group to reduce significant competencies
to trivial—but measurable—tasks. This tendency is called atrophy. (For instance, “List three types of health plan outcome
measures.”)
z Focusing on activities or particular learning situations can obscure the intent behind a competency. (For example,
“Accompany a health official to a legislative hearing,” “Describe the functions of the divisions within the State Department
of Public Health.”)
z Groups may exemplify contradictory tendencies toward developing, on one hand, a detailed “wish list” of desirable
competencies in the area; and on the other, a cautious, restrictive list, possibly based on concerns that these competencies
will ultimately be appropriated for use in accreditation and certification.
z In considering how to evaluate achievement of competencies, groups may suggest using a scale along which residents can
be rated at several points ranging from poor to excellent performance. We found it important to remember that
competencies do not lend themselves to this type of evaluation. One is either competent or not; rating a resident “a little
bit competent” renders the term meaningless.
z Groups often disagree about whether residents can be offered sufficient responsibility during their training or if additional
practice experience is required to assure competency in a particular area. (For example, “demonstrate effective leadership
capabilities.” In this case, demonstration of elements of leadership, e.g., “development of a shared strategy,” can be
accepted as evidence of the ability to assume real leadership roles on the job).
z Groups are often divided about whether to use current terminology or jargon in their competency definitions or whether
to use language that addresses underlying skills (for example, “TQM” versus “quality assurance”). Recognizing that the
limited use of “buzzwords” may be considered to be important evidence of relevance to current practice, it is at least as
important to use language that will be understandable to a broad, general audience and that will remain understandable
even after current buzzwords are replaced by newer ones.

cation of techniques such as process improvement, financial management reports and development of
benchmarking, outcomes assessment, and clinical recommendations to enhance organizational effec-
epidemiology. tiveness.
d. analysis of the impact of managed care (e.g., HMO, b. use of techniques such as cost-effectiveness analysis,
POS, PPO) and other health service delivery sys- cost-benefit analysis, and decision analysis (includ-
tems/reimbursement models (e.g., fee for service, ing prioritization) to allocate and manage clinical
third-party payer, managed indemnity) on the and financial resources.
health of defined populations, patient, payor, and c. preparation of a business and financial plan that
provider needs and behaviors, and organizational incorporates basic accounting principles (e.g., anal-
performance. ysis of balance sheet, income statements, proforma
e. use of marketing strategies to promote appropriate projections, statement of cash flow), and techniques
participation in a population-based health service, to such as cost accounting, pricing of services, analysis
alter patient, provider, or organizational behavior in of return on investment, market prediction and
order to improve health and the delivery of health analysis, economic valuation of service to client and
services, and/or to support the development of group, recognition of the need for capital formation
health care products or services. and budget development to evaluate current or
f. use of systematically collected data to prioritize proposed health care products or services.
system problems, identify and implement best prac-
d. assessment, negotiation, and management of pro-
tices, continue to improve service delivery, and
vider contracts, including such issues as basis of
assure appropriate utilization of services.
payment (e.g., capitation, fee-for-service), risk-shar-
g. evaluation of the effectiveness, medical necessity,
ing, and reporting requirements.
and appropriate use of products and interventions.
e. preparation of a strategic plan that analyzes the
h. design of systems of care that meet patient needs for
external environment (including competition and
access and acceptability, and measurement of pa-
legislative regulatory changes), the internal environ-
tient satisfaction with these systems.
ment (including staffing and ethical issues), and
Financial Management strengths, weaknesses, opportunities, and threats
2. Apply appropriate financial and business manage- related to the success of the enterprise.
ment techniques to assure efficient delivery of cost-
f. analysis of insurance principles (e.g., adverse selec-
effective health services.
tion, law of large numbers, risk analysis, communi-
This reflects demonstrated ability in: ty/experience rating) and ways insurance benefits
a. critical interpretation of capitation and standard are packaged, priced, and implemented to facilitate

Am J Prev Med 1998;14(3) 233


the provision of quality health care and avoid busi- sibilities. In the past, this has primarily involved the
ness problems. health of geographic populations served by health
departments or of workers in occupational medicine
Organizational Management
settings. The current transformation that we have un-
3. Apply organizational principles to manage a health
dergone in the organization of health services, with
care organization or unit.
tremendous expansion in the delivery and financing of
This reflects demonstrated ability in: health care through managed care arrangements, has
a. determination of management information needs increased the need for physicians with knowledge and
and use of medical informatics, electronic health skills in population medicine and medical manage-
and patient care data, and management information ment. Increasing numbers of our limited supply of
systems. preventive medicine specialists are being recruited to
b. appropriate use of human resources management positions within managed care and other private sector
principles in selection, retention, promotion, moti- health care organizations. These physicians have felt
vation, appraisal, and discipline of employees; and the need for further knowledge and skills, particularly
in managing workforce diversity. in areas relating to changes in health care financing
c. appropriate use of management principles in con- and organizational structure.
flict resolution, negotiation, consensus building, At the same time, there has been recognition of the
problem solving, team building, and change man- importance of medical management on the part of
agement. many mid-career physicians, already experienced in
d. effective leadership capabilities, including creation clinical practice, who because of their interest and
of a vision, development of a shared strategy, coor- leadership abilities are being attracted to assume high-
dination of affected parties and resources, and com- level medical management responsibilities with little or
munication with stakeholders. no training for these newfound responsibilities. Many
Legal and Ethical Considerations of these physicians have turned to continuing medical
4. Assure that health service activities reflect ethical education courses (e.g., such as those offered by ACPE)
standards, comply with all pertinent legal and regu- to help fill their knowledge deficit. It has become clear,
latory requirements (e.g., ERISA, ADA), and incor- however, that CME courses or even a business degree
porate risk management principles and practices. and on-the-job situational self-teaching is not enough.
Population medicine skills, which are rooted in epide-
This reflects demonstrated ability in: miology and biostatistics, are needed to meet societal
a. identification and analysis of an ethical issue in a and health care organization needs. Schools of Public
health care setting (e.g., access to bone marrow Health and other academic institutions have begun to
transplant) and effective communication of a rec- develop areas of concentration or fellowships in health
ommended resolution. policy and management; similarly, existing preventive
b. identification and analysis of a liability issue in a medicine residency programs are developing tracks in
health care setting, and design and communication health services and systems management that can serve
of a risk reduction strategy. as precursors of future residency training in managerial
c. incorporation of knowledge of statutes, regulations, medicine.
case law, contract law, administrative law, and regu- Combined with competencies in clinical and popu-
lations and accreditation requirements in the oper- lation-based medicine, the medical management com-
ation of health care organizations in areas such as petencies and performance indicators can provide a
liability, restraint of trade, conflict of interest, privi-
framework for developing new residency training pro-
leging, credentialing, certification practices, confi-
grams in this area. Such an educational program devel-
dentiality, discrimination, and unionism.
opment process, moving in tandem with efforts to
d. influencing state and federal legislative and regula-
achieve certification through the American Board of
tory processes toward the goal of creating or reward-
Medical Specialties and residency training accredita-
ing health care systems and interventions that en-
tion by the Accreditation Council on Graduate Medical
hance the health of our communities.
Education, will expedite meeting the needs of the
current and future health care environment.
Conclusions
This project was funded under HRSA contract number
All of the preventive medicine specialty areas or fields 103HR960424P000-000. D.W. Chen, MD, MPH, is Deputy
of practice share a common body of knowledge and Director of the Division of Associated Dental and Public
skills in management and administration, and the Health Professions and the government project officer for
majority of physicians practicing preventive medicine this contract is Anne Kahl, MA. The members of the HRSA/
continue to have health services management respon- ACPM Medical Management work group who developed the

234 American Journal of Preventive Medicine, Volume 14, Number 3


Appendix HRSA/ACPM WORKGROUP ON MEDICAL MANAGEMENT COMPETENCIES
Name Title

Dorothy S. Lane, MD, MPH, Chair Professor of Preventive Medicine


Director, Preventive Medicine Residency Program
School of Medicine
State University of New York at Stony Brook
Stony Brook, New York
Richard L. Buck, MD, MPH, Vice Chair Commanding Officer
Navy Environmental Health Center
Norfolk, Virginia
Robert Amster, MD, MBA Medical Director
Worker’s Comp-Blue Cross of California
Costa Mesa, California
George K. Anderson, MD, MPH Fellow, Koop Foundation
Rockville, Maryland
Robert W. Beardall, MD, MPH Director, Medical Affairs
EDS Health Care Division
Plano, Texas
Robert Harmon, MD, MPH National Medical Director
United Healthcare Corp.
McLean, Virginia
Nick Korns, MD, MPH Vice President, Medical Management
Private Healthcare Systems
Glastonbury, Connecticut
Marie Krousel-Wood, MD, MSPH Director, Preventive Medicine Residency Program
Tulane School of Medicine
New Orleans, Louisiana
Paul R. Lenz, MD President, Managed Care Consulting International
Colts Neck, New Jersey
Marc Miller, MD, MBA Associate Vice President, Center Administrator
Talbert Medical Management Corporation
Huntington Beach, California
Royce Moser, Jr., MD, MPH Professor and Director
Rocky Mountain Center for Occupational and Environmental Health
Salt Lake City, Utah
Michael F. Noe, MD, MPH Executive Vice President and Medical Director
Buffalo General Health Systems
Buffalo, New York
Bruno P. Petruccelli, MD, MPH Director, Preventive Medicine Residency Program
Division of Preventive Medicine
Walter Reed Army Institute of Research
Washington, DC
Virginia Ross, PhD, Facilitator Medical Writer, Consultant
Decatur, Georgia

competencies and performance indicators appear in the 4. Nash DB, Markson LE, Howell S, Hildreth EA. Evaluating
Appendix. The authors also acknowledge the important the competence of physicians in practice: from peer
contribution of Carol O’Neill, Director of Education, and review to performance assessment. Acad Med 1993;
Hazel Keimowitz, Executive Director, of the American Col- 68(Suppl 1):S19 –S22.
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meeting management and integrating the project with ongo- medicine and public health: a national survey of resi-
ing ACPM activities. dency graduates. Acad Med 1996;71:375– 80.
6. Lane DS, Ross V. Consensus on core competencies for
preventive medicine residents. Am J Prev Med 1994;10:
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236 American Journal of Preventive Medicine, Volume 14, Number 3

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