Douglas Char, MD FACEP FAAEMCORD Academic AssemblyMarch 2013
We are at a tipping point in competency-based medical education (CBME) and its only taken 40 years since the competency conversation first appeared in the medical literature! In case you were not aboard the CBME train as it left the station, this concept is an integrated framework for education, in which specific behavioral outcomes (competencies) drive both medical school curricula and individual advancement, rather than the current driving forces of time (four years of medical school) and process (clerkships of specific length). Carol Aschenbrener Chief Medical Officer, AAMChttp://wingofzock.org/2012/09/25/competency-based-medical-education-the-time-is-now/
Traditional medical education presumes that all students are ready to graduate once they have completed a set number of years of study and passed the required assessments, There is a growing interest in tailoring the length as well as the content of medical education to individual aptitudes.People learn in different ways and at different speeds, As early as 1932, reports emerged saying that it is not enough to stuff students heads with informationhttps://www.aamc.org/newsroom/reporter/april11/184286/competency-based_medical_education.html
No longer accepting them (residents) as independent actors, they expect physicians to function as leaders and participants in team-oriented care. Patients, payers, and the public demand information-technology literacy, sensitivity to cost-effectiveness, the ability to involve patients in their own care, and the use of health information technology to improve care for individuals and populations Expect that GME will help to develop practitioners who possess these skills along with the requisite clinical and professional attributesNasca TJ. NEJM 2012, 366;11:1051-1056
It is a curricular concept designed to provide the skills physicians need, rather than solely a large, prefabricated collection of knowledge. A medical school or residency program using competency-based medical education defines a set of skills or competencies based on societal and patient needs, such as medical knowledge, patient care, or communications approaches, and then develops ways to teach that content across a range of courses and settings.https://www.aamc.org/newsroom/reporter/april11/184286/competency-based_medical_education.htmlThe competency-based approach still includes scientific knowledge, but in the broader context of a physicians tasks as a healer.
Educational milestones (developmentally based, specialty specific achievements that residents are expected to demonstrate at established intervals as they progress through training)NAS moves the ACGME from an episodic biopsy model to annual data collection. Each review committee will perform an annual evaluation of trends in key performance measurements and will extend the period between scheduled accreditation visits to10 yearsNAS is more than just Milestones!!Nasca TJ. NEJM 2012, 366;11:1051-1056
We are wrestling with it just like everyone else. The challenge is not so much accepting the concept, which we think is great, but figuring out how to make it work. Where do we teach? How do we evaluate performance? How do we remediate students who have not met requirements? Thomas Pellegrino - EVMSHow to define competencies, and how to assess performance are perhaps the two most significant concerns about competency-based medical education. Peter Katsufrakis NBMEweve been wrestling with this question for decades, M. Brownell Anderson - AAMC
A competency-based approach to medical education relies on continuous, comprehensive, and elaborate assessment and feedback systems. Ideally, a major portion of the assessments should be performed in the context of the clinical workplace and should be criterion-referenced. Assessment facilitates the developmental progression ofcompetence. A number of useful assessment methods already exist; work should focus on helping training programs use such methods more effectively. New assessment tools and approaches will need to be developed for new competencies such as teamwork, systems, and quality improvement, among others, to fully realize the promise of CBMEHolmboe E., Med Teach 2010, 32(8):676-682
Implementing competency-based training in postgraduate medical education poses many challenges. Making this transition requires change at virtually all levels of postgraduate training.Key components of this change include; Development of valid and reliable assessment tools such as work-based assessment using direct observation, Frequent formative feedbackLearner self-directed assessment; Active involvement of the learner in the educational process; Intensive faculty development that addresses curricular design and the assessment of competencyIobst. Teach Med 2010; 32: 651656
Measurement and reporting of outcomes through the educational milestones, which is a natural progression of the work on the six competenciesAim is to create a logical trajectory of professional development in essential elements of competency and meet criteria for effective assessment, including feasibility, demonstration of beneficial effect on learning, and acceptability in the communityData represent the consensus of the assessment committee on the educational achievements of residents, informed by evaluations the program has performedNasca TJ. NEJM 2012, 366;11:1051-1056
Blooms Taxonomy 1956Andersons revision 2000Cognitive (Knowledge) Affective (Attitude) Psychomotor (Skills)
Remembering: can the student recall or remember the information?define, duplicate, list, memorize, recall, repeat, reproduce stateUnderstanding: can the student explain ideas or concepts?classify, describe, discuss, explain, identify, locate, recognize, report, select, translate, paraphraseApplying: can the student use the information in a new way?choose, demonstrate, dramatize, employ, illustrate, interpret, operate, schedule, sketch, solve, use, write. Analyzing: can the student distinguish between the different parts?appraise, compare, contrast, criticize, differentiate, discriminate, distinguish, examine, experiment, question, test. Evaluating: can the student justify a stand or decision?appraise, argue, defend, judge, select, support, value, evaluateCreating: can the student create new product or point of view?assemble, construct, create, design, develop, formulate, write
Its was never expected to be simple or straightforward
Final milestones will provide meaningful data on the performance that graduates must achieve before entering unsupervised practice (graduate)Initial milestones for entering residents will add a performance- based vocabulary to conversations with medical schools about graduates preparedness for supervised practice (residency)
Norcini BMJ 2003:326(5):753-755Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990:S63-7.
Many people argue that this statement is incorrect and that the curriculum is the key in any clinical course.
In reality, students feel overloaded by work and respond by studying only for the parts of the course that are assessed. To promote learning, assessment should be educational and formativestudents should learn from tests and receive feedback on which to build their knowledge and skillsPragmatically, assessment is the most appropriate engine on which to harness the curriculum.V Wass. Lancet 2001; 357: 94549
Trained ObserversCommon understanding of expectationsSensitive eye to key elementsConsistent evaluation of a given level of performanceMinimum number of quality observationsAssessment based on 6 observations felt to be valid and reliableInterpreter/Synthesizer ExpertsClinical Competency Committee
Numbers produce range restrictionNarratives are easily understood by faculty and produce data without range restriction Natural to how we teach and provide feedback
Goalis to create verbal pictures 4 cm laceration right arm vs
1990s The Royal College developed an innovative, competency-based framework that describes the core knowledge, skills and abilities of specialist physicians. formally adopted by the Royal College in 1996CanMEDS Springboards Mobile App - The first in a series of specialty-specific teaching resources, the CanMEDS Springboards mobile app for Emergency Medicine is designed to help busy clinicians teach around the CanMEDS Roles during patient care. For iPhone, iTouch and iPad only.
Danger here is that rather than engaging a total practicum to which other forms of learning discourse bring their insights, a limited professional education is based upon an inappropriate epistemology of competency Tendency to limit the reflection, intuition, experience and higher order competence necessary for expert, holistic or well developed practice
Martin Talbot, Med Educ 2004; 38: 587592
If your are feeling overwhelmed and confused by all this new jargon you are not aloneYour faculty are looking to you for answers!Nobody has all the answers so stop waiting for the Holy Grail?Better to join the legion of PDs working to define itThere is no way to sort out the milestones without getting dirty expect to make mistakesAssessment is suppose to drive curriculum (this is a game changer)Resistance if futile, give in and drink the kool aidReduce your stress, its going to happen!
Bloom's Taxonomy divides educational objectives into three "domains": Cognitive, Affective, and Psychomotor (sometimes loosely described as knowing/head, feeling/heart and doing/hands respectively). Within the domains, learning at the higher levels is dependent on having attained prerequisite knowledge and skills at lower levels. A goal of Bloom's Taxonomy is to motivate educators to focus on all three domains, creating a more holistic form of education.A revised version of the taxonomy was created in 2000
*Bloom's Taxonomy divides educational objectives into three "domains": Cognitive, Affective, and Psychomotor (sometimes loosely described as knowing/head, feeling/heart and doing/hands respectively). Within the domains, learning at the higher levels is dependent on having attained prerequisite knowledge and skills at lower levels. A goal of Bloom's Taxonomy is to motivate educators to focus on all three domains, creating a more holistic form of education.A revised version of the taxonomy was created in 2000
*In 1990 psychologist George Miller proposed a framework for assessing clinical competence. At the lowest level of the pyramid is knowledge (knows), followed by competence (knows how), performance (shows how), and action (does). In this framework, Miller distinguished between action and the lower levels. Action focuses on what occurs in practice rather than what happens in an artificial testing situation
Work based methods of assessment target this highest level of the pyramid and collect information about doctors performance in their normal practice. Other common methods of assessment, such as multiple choice questions, simulation tests, and objective structured clinical examinations (OSCEs) target the lower levelsof the pyramid. Underlying this distinction is the sensible but still unproved assumption that assessments of actual practice are a much better reflection of routine performance than assessments done under test conditions.
John J Norcini BMJ Apr 2003; 326(5) 753-755*