The analysis of Taiwan emergency physician’s core competencies base on the ACGME idea

The development of the core competence of physicians is related to the practice of medical quality. As the most important field for cultivating the core competence of physicians, how to achieve the construction and evaluation of core competence is an important issue for medical education and management. This study uses the large core competence framework proposed by the ACGME (Accreditation Council for Graduate Medical Education), and use Fuzzy AHP (FAHP) and DEMANTEL method to analyze the weight and priority, and the cause and effect cluster. Study result shows that the FAHP’s importance factor ranking is (1).patient care (C1) (27.83%), (2).medical knowledge (C2) (20.77%), (3).professionalism (C5) (17.93%), (4). Interpersonal and communication skills (C4) (17.41%), (5). practice-based learning and improvement (C3) (15.52%), and (6). systems-based practice (C6) (8.233%). In terms of DEMANTEL, the effect cluster include Patient Care (C1), Professionalism (C5) and Systems-based practice (C6), and the cause cluster includes Medical Knowledge (C2), Practice-based learning and improvement (C3) and Interpersonal and Communication skills (C4). According to finding, the patient care (C1) is the result of attitude, patience, and other five ACGME Core Competence Items. Therefore, the development of emergency physicians’ also needs humanities and ethics training and practice to follows the practice-based learning (C3). This study demonstrates to show on importance factor in emergency physician’s core competencies cultivate. Furthermore, the current ﬁndings can serve as a reference for future research in the other specialists physicians cultivate.


Introduction
In the past, the literature discusses the core competences that physicians should possess.
Most of them are based on the core competences that physicians should have in the United States Medical Education Evaluation Board (ACGME). They propose effective and useful methods for assessing core competences, and can improve the core competence. Competent 3 education and training methods (Leach, 2002;Freyet al., 2003;Ogrinc et al., 2003;Johnson et al., 2004;Joyner, 2004). Frey et al. (2003) pointed out that the core competence proposed by ACGME is to confirm whether residents have the core competence. Massagli & Carline (2007) questionnaire study found that senior residents had higher grades than less resident residents. Second, their factor analysis results also indicate that ACGME's large core capabilities can effectively assess the capabilities of residents. Powers, J., (2013) points that assessment of electronic portfolios for ACGME Core Competencies may have to await more robust vocabulary to create concept identifiers capable of responding to issues of context for competencies such as ACGME Core Competencies reflecting sociologic and anthropologic content.
The development of physician's core competencies is related to the medical quality learning. The hospital is the most important place to cultivate the core competence of the physician. It has the training plan, the learning environment of the organization, whether it can inherit and develop the core competence of the physician and further validate it, is an important subject of medical management and medical education. In this study, the six core competency frameworks presented by the ACGME (Accreditation Council for Graduate Medical Education) were used to inquire and investigate the findings of the emergency physicians and try to identify possible priorities and interdependent relationships and dependency.

Literature review
This study attempts to collect relevant literature on the core competencies of the emergency department and the large core competencies of the ACGM (Accreditation Council for Graduate Medical Education).

Core Competence:
The ACGME (Accreditation Council for Graduate Medical Education) takes the American Board of Internal Medicine (ABIM) as a case, and evaluates the results of the Residents' Training Program (Outcome project). A competent physician should have six core competencies (Kissela et al., 2006).
In the past, the literature has discussed the core competences that physicians should possess. Most of them are based on the core competences that physicians should have in the United States Medical Education Evaluation Board (ACGME). They propose effective and 4 useful methods for assessing core competences, and can improve the core competence (Leach, 2002;Freyet al., 2003;Ogrinc et al., 2003;Johnson et al., 2004;Joyner, 2004). (Frey et al., 2003) study shown on, the relevant literature discussed the focus on "The Education and Training Methods to Enhance Core Competence", and mentions that providing good clinical experience and mixing practical operations in different fields to improve the core competence that residents physicians should have it. Frey et al. (2003) pointed out that the core competence proposed by ACGME is to confirm whether residents have the core competence. Massagli & Carline (2007) questionnaire study found that senior residents had higher grades than less resident residents. Second, their factor analysis results also indicate that ACGME's large core capabilities can effectively assess the capabilities of residents. Powers, J., (2013) points that assessment of electronic portfolios for ACGME Core Competencies may have to await more robust vocabulary to create concept identifiers capable of responding to issues of context for competencies such as ACGME Core Competencies reflecting sociologic and anthropologic content.

ACGME (Accreditation Council for Graduate Medical Education)
In the year of 1991, the Physician's core competence established by the American Medical Education Committee (ACGME, Accreditation Council for Graduate Medical Education) : • Show concern and respect when interacting with patients and family members; • Collect necessary and accurate information during interviews with patients; • Can make informed decisions about diagnosis and treatment based on patient information and their wishes, the latest scientific evidence, and clinical judgment • Formulate and implement patient treatment plans; • Consultation and health education for patients and their families; • Decision-making and health education using information technology and supporting patient care • Fully capable of performing medical and invasive procedures required for practice • Prevention of disease or the provision of relevant medical care; • Share work with other medical professionals to provide patient-centric medical care.

C2 Medical Knowledge
• Show concern and respect when interacting with patients and family members; • Collect necessary and accurate information during interviews with patients; • Can make informed decisions about diagnosis and treatment based on patient information and their wishes, the latest scientific evidence, and clinical judgment C3 Practice-based learning and improvement) • Self-reflective assessment learning； Interpersonal and communication skills • Establish and maintain appropriate medical and ethical relationships with patients; • Use effective listening skills and use effective non-spoken, narrative, questioning, and writing skills to elicit and provide information; • Work effectively with members of the same and cross-cutting medical team.

C5 Professionalism
• Altruism and respect for others; • Medical behaviors consistent with medical ethical principles; • Can be sensitive to differences in other people's culture, age, gender, and disability C6 Systems-based practice • Understand how your own medical care for patient care and other medical personnel affects other medical personnel, medical institutions and the social environment, and how each element of these systems affects your own medical operations; • Know the differences between the models of medical operations and care systems, including methods of cost control and resource allocation; • Implement cost-effective medical care and resource allocation without compromising quality of care; • Promote quality patient care and help patients deal with the complexities of the system; • Know how to work with health care managers and health care providers to evaluate, coordinate, and improve health care, and understand how these activities can affect system performance.
Data source#: ACGME (Accreditation Council for Graduate Medical Education) 6 3 Methodology

Methodology choice
This study serves as evaluating the relative importance of core competencies to the emergency physicians in Taiwan. Two multi-criteria decision-making methodologies said Fuzzy AHP (FAHP) and DEMATEL, using expert opinion input, are used for the relative importance of practices determination.

Questionnaire design
This study uses ACGME six core competence items as Fuzzy AHP (Saaty, 1980 ;Herrera et al., 2004) Table 2) and a confidence index with an interval mean approach to determine the weights for evaluative elements; therefore, this method is suitable for analyzing small samples of questionnaire feedback provided by Taiwan emergency physicians' expert.  (Chang, 1996)  The procedures involved in executing the FAHP method are outlined as follows.
Step 1: Construct pairwise comparison matrices among all the criteria in the dimensions of the hierarchical system. Assign linguistic terms to the pairwise comparisons by determining which is the more important of every two dimensions, as indicated in the following matrix ̃ (shown in equation (1)): Where ̃i j = { 9 −1 , 8 −1 , 7 −1 , 6 −1 , 5 −1 , 4 −1 , 3 −1 , 2 −1 1 −1 , 1, 2, 3, 4, 5, 6, 7, 8, 9, 1, ≠ 1 = Step 2: Apply the geometric mean technique to define the fuzzy geometric mean and fuzzy weights of each criterion, as demonstrated by Hsieh et al. (2004) (shown in equation (2)): In this equation (2), α ij is the fuzzy comparison value of dimension i with criterion j ; thus, γ is the geometric mean of the fuzzy comparison values of criterion i with each other criterion. In addition, The FAHP framework is constructed in the form of a matrix, and a local priority vector can be derived as an estimate of relative importance associated with the components being compared by solving the equation (3): where A is the matrix of the pair-wise comparison, w is the eigenvector, and max  is the maximum eigenvalue. Saaty (1996)  Where R.I represents the average CI obtained from numerous simulation runs, and it varies according to the matrix order (Table 2).  acceptable inconsistency limit should be 0.1 (Saaty, 1980).

Analyses process：
Step 1: acquire and compute the average initial matrix Suppose L experts and n factors are considered in a study. A pair-wise comparison with respect to the influence of factor i on factor j is determined ( ) and is quantified using a 4-point (0-3) measurement scale. See 3.3.1 for the linguistic assignments of each level of the scale. Each expert will be asked to provide a completed n × n non-negative response matrix = [ ], with 1 ≤ x ≤ . Where 1 , 2 , … represents each of the experts response matrices, is an integer (scale measure) representing each element of and diagonal elements of each response matrix set to zero.
An averaged n × n matrix using all the experts' comparisons is determined by averaging the L experts' scores using expression (1): Step 2: compute the normalized initial direct-relation matrix D There is normalized the direct relation matrix, that is multiply the elements of the entire matrix A by S, Then, it can be get a normalized initial direct-relation matrix D, Step 3

Research object
This study is based on the architecture of a physician's core competence established by the ACGME (Accritation Council for Graduate Medical Education) (Show on Figure 1)

Sampling
In this study, we collected in the Taiwan teaching hospital with teaching duty of the attending physician (Visiting Staff) above the emergency physicians by the questionnaire objective.

Ethic requirement
This is study are use FAHP and DEMATEL questionnaire to inquire the physician (Visiting Staff) above the emergency physicians opinion, and we don't use medical record, therefore we don't need to approval with the ethics committee.
This study all of methods were carried out in accordance with relevant guidelines and regulations.
This questionnaire is emergency physicians reply after filling out, so they know and are willing to reply.

Results
In this study, we totally collective 21 Taiwan emergency physicians questionnaire, and the descriptive statistics are as follows: (Show on Table 4).

DEMANTEL analysis process
As follows 3.3.2 analyses process and found result below: Step 1: Acquire and compute the average initial matrix A by 21 Taiwan emergency physicians questionnaire. The resulted show on table 6. Step 2: Compute the normalized initial direct-relation matrix D, show on table 7. Step 3: Compute the total relation matrix T, show on table 8. Step 4 Table 9.

Drawing causal diagram
The graphical representation (the prominence-causal diagram) and digraphical relationships are now constructed. This step will allow a clearer visualization of the structure and relationships amongst the emergency physicians' core competencies criteria. One of the first activities of this sub-step is to plot the various emergency physicians' core competencies criteria on a two-axes the prominence horizontal axis (R + D) and the net cause/effect vertical axis (R -D) (Show on Figure 4). There are can help us observe general patterns and relationships amongst all the programs simultaneously and in pairs. For example, we can see that C3 have very stronger influence/effect on the other programs, and is more of an effect or influenced by others.
The development of the digraphs in Figure 4 shows the interrelationships amongst each of the individual core competencies selection criteria. We can also observe general clusters into cause and effect groups. Generally the core competencies selection criteria that are part of the effect cluster include C1, C5 and C6; the cause cluster includes C2, 15 C3 and C4. The causal relationships among core competencies selection criteria can be depicted as the causal diagram (Show on Figure 4).this figure is shown that Practicebased learning and improvement (C3) is the most influence and the strongest connection to other criteria.

Conclusion and Discussion
This study uses the fuzzy AHP and DEMATEL methods to analyze the relative importance factors of Taiwan emergency physicians' core competencies. The results of this study may hopefully help the emergency physicians that core competencies are crucial factors found in this study. From the fuzzy AHP results, we can understand that first-ranked important is Patient Care (C1) (27.83%). Moreover, the second-ranked important is Medical Knowledge (C2) (20.77%), and the third-ranked important is Professionalism (C5) (17.93%). Therefore, the medical education managers should be pay special attention to Patient Care.
The development of the digraphs in Figure 4 shows the interrelationships amongst each of the individual core competence items. We can also observe general clusters into Cause and Effect Groups. Generally the core competence items that are part of the effect cluster include From the DEMATEL results, we can understand the Practice-based learning and improvement (C3) is the most influence and the strongest connection to other criteria.
According to DEMATEL analysis results, the Practice-based learning and improvement (C3) could directly or indirectly influence many other characteristics such as Medical Knowledge (C2) and Interpersonal and Communication skills (C4). One major limitation is the evaluation effort required with these techniques. Any combination of the ACGME five entries reflects all competencies with the exception of practice-based learning (C3). This deficit can be corrected with revision of portfolio guidelines. (Jarviset, etc., 2004). The patient care (C1) is the result of attitude, patience, and other five ACGME Core Competence Items. Therefore, the development of emergency physicians also needs humanities and ethics training and practice to follows the practice-based learning by this research finding.
In this study, we present Fuzzy AHP and DEMATEL as a generalized method to the relative importance factors of Taiwan emergency physicians' core competencies under a fuzzy environment.

Limitations and Further Research
For this study evaluators to each method (Fuzzy AHP and DEMATEL) had to each complete six comparisons (ACGME six core competencies). Fatigue is easily a possibility which may cause some confuse problems.
There are other multiple attribute decision-making methods such as Fuzzy ANP, TOPSIS and ELECTRE, which could be applied for ranking and relative the Taiwan emergency physician's criteria.
Further research, it may be the application of these methods to the other specialists physician's core competencies evaluation and the comparison of the results.