Implementation of competency-based medical education: are we addressing the concerns and challenges?

CONTEXT: Competency-based medical education (CBME) has emerged as a core strategy to educate and assess the next generation of physicians. Advantages of CBME include: a focus on outcomes and learner achievement; requirements for multifaceted assessment that embraces formative and summative approaches; support of a flexible, time-independent trajectory through the curriculum; and increased accountability to stakeholders with a shared set of expectations and a common language for education, assessment and regulation. OBJECTIVES: Despite the advantages of CBME, numerous concerns and challenges to the implementation of CBME frameworks have been described, including: increased administrative requirements; the need for faculty development; the lack of models for flexible curricula, and inconsistencies in terms and definitions. Additionally, there are concerns about reductionist approaches to assessment in CBME, lack of good assessments for some competencies, and whether CBME frameworks include domains of current importance. This study will outline these issues and discuss the responses of the medical education community. METHODS: The concerns and challenges expressed are primarily categorised as: (i) those related to practical, administrative and logistical challenges in implementing CBME frameworks, and (ii) those with more conceptual or theoretical bases. The responses of the education community to these issues are then summarised. CONCLUSIONS: The education community has begun to address the challenges involved in implementing CBME. Models and guidance exist to inform implementation strategies across the continuum of education, and focus on the more efficient use of resources and technology, and the use of milestones and entrustable professional activities-based frameworks. Inconsistencies in CBME definitions and frameworks remain a significant obstacle. Evolution in assessment approaches from in vitro task-based methods to in vivo integrated approaches is responsive to many of the theoretical and conceptual concerns about CBME, but much work remains to be done to bring rigour and quality to work-based assessment.

A Redesign of the ACGME Resident/Fellow Survey Through Expert Reviews and Cognitive Interviews.

Background: Since 2003, the Accreditation Council for Graduate Medical Education (ACGME) has surveyed residents and fellows in its accredited programs. The Resident/Fellow Survey is a screening and compliance tool that programs can also use for continuous quality improvement. However, stakeholders have reported potential problems with the survey's overall quality and credibility. Objective: To redesign the 2006 Resident/Fellow Survey using expert reviews and cognitive interviews. Methods: In 2018-2019, the ACGME redesigned the Resident/Fellow Survey using an iterative validation process: expert reviews (evidence based on content) and cognitive interviews (evidence based on response processes). Expert reviews were conducted by a survey design firm and an ACGME Task Force; cognitive interviews were conducted with a diverse set of 27 residents and fellows. Results: Expert reviews resulted in 21 new survey items to address the ACGME's updated accreditation requirements; these reviews also led to improvements that align the survey items with evidence-informed standards. After these changes were made, cognitive interviews resulted in additional revisions to sensitive items, item order, and response option order, labels, and conceptual spacing. In all, cognitive interviews led to 11 item deletions and other improvements designed to reduce response error. Conclusions: Expert reviews and cognitive interviews were used to redesign the Resident/Fellow Survey. The content of the redesigned survey aligns with the updated accreditation requirements and items are written in accordance with evidence-informed standards. Additionally, cognitive interviews resulted in revisions to the survey that seem to improve respondents' comprehension and willingness to respond to individual survey items.

Beyond Training the Next Generation of Physicians: The Unmeasured Value Added by Residents to Teaching Hospitals and Communities.

Following medical school, most newly graduated physicians enter residency training. This period of graduate medical education (GME) is critical to creating a physician workforce with the specialized skills needed to care for the population. Completing GME training is also a requirement for obtaining medical licensure in all 50 states. Yet, crucial federal and state funding for GME is capped, creating a bottleneck in training an adequate physician workforce to meet future patient care needs. Thus, additional GME funding is needed to train more physicians. When considering this additional GME funding, it is imperative to take into account not only the future physician workforce but also the value added by residents to teaching hospitals and communities during their training. Residents positively affect patient care and health care delivery, providing intrinsic and often unmeasured value to patients, the hospital, the local community, the research enterprise, and undergraduate medical education. This added value is often overlooked in decisions regarding GME funding allocation. In this article, the authors underscore the value provided by residents to their training institutions and communities, with a focus on current and recent events, including the global COVID-19 pandemic and teaching hospital closures.

Beyond the United States Medical Licensing Examination Score: Assessing Competence for Entering Residency.

Assessments of physician learners during the transition from undergraduate to graduate medical education generate information that may inform their learning and improvement needs, determine readiness to move along the medical education continuum, and predict success in their residency programs. To achieve a constructive transition for the learner, residency program, and patients, high-quality assessments should provide meaningful information regarding applicant characteristics, academic achievement, and competence that lead to a suitable match between the learner and the residency program's culture and focus.The authors discuss alternative assessment models that may correlate with resident physician clinical performance and patient care outcomes. Currently, passing the United States Medical Licensing Examination Step examinations provides one element of reliable assessment data that could inform judgments about a learner's likelihood for success in residency. Yet, learner capabilities in areas beyond those traditionally valued in future physicians, such as life experiences, community engagement, language skills, and leadership attributes, are not afforded the same level of influence when candidate selections are made.While promising new methods of screening and assessment-such as objective structured clinical examinations, holistic assessments, and competency-based assessments-have attracted increased attention in the medical education community, currently they may be expensive, be less psychometrically sound, lack a national comparison group, or be complicated to administer. Future research and experimentation are needed to establish measures that can best meet the needs of programs, faculty, staff, students, and, more importantly, patients.

A Team Disclosure of Error Educational Activity: Objective Outcomes.

Medical errors can involve multiple team members. Few curricula are being developed to provide instruction on disclosing medical errors that include simulation training with interprofessional team disclosure. To explore more objective evidence for the value of an educational activity on team disclosure of errors, faculty developed and assessed the effectiveness of a multimodal educational activity for learning team-based disclosure of a medical error. This study employed a methodological triangulation research design. Participants (N = 458) included students enrolled in academic programs at three separate institutions. The activity allowed students to practice team communication while: (1) discussing a medical error within the team; (2) planning for the disclosure of the error; and (3) conducting the disclosure. Faculty assessed individual student's change in knowledge and, using a rubric, rated the performance of the student teams during a simulation with a standardized family member (SFM). Students had a high level of preexisting knowledge and demonstrated the greatest knowledge gains in questions regarding the approach to disclosure (P < .001) and timing of an apology (P < .001). Both SFMs and individual students rated the team error disclosure behavior highly (rho = 0.54; P < .001). Most participants (more than 80%) felt the activity was worth their time and that they were more comfortable with disclosing a medical error as a result of having completed the activity. This activity for interprofessional simulation of team-based disclosure of a medical error was effective for teaching students about and how to perform this type of important disclosure.

Faculty development for the 21st century: lessons from the Society of General Internal Medicine-Hartford Collaborative Centers for the Care of Older Adults.

In this review of a recent set of faculty development initiatives to promote geriatrics teaching by general internists, nontraditional strategies to promote sustained change were identified, included enrolling a limited number of "star" faculty, creating ongoing working relationships between faculty, and developing projects for clinical or education program improvement. External funding, although limited, garnered administration support and was associated with changes in individual career trajectories. Activities to enfranchise top leadership were felt essential to sustain change. Traditional faculty development programs for clinician educators are periodic, seminar-based interventions to enhance teaching and clinical skills. In 2003/04 the Collaborative Centers for Research and Education in the Care of Older Adults were funded by the John A. Hartford Foundation and administered by the Society of General Internal Medicine. Ten academic medical centers received individual grants of $91,000, with required cost sharing, to develop collaborations between general internists and geriatricians to create sustained change in geriatrics clinical teaching and learning. Through written and structured telephone surveys, activities designed to foster sustainability at funded sites were identified, and the activities and perceived effects of funding at the 10 funded sites were compared with those of the 11 highest-ranking unfunded sites. The experience of the Collaborative Centers supports the conclusion that modest, targeted funding can provide the credibility and legitimacy crucial for clinician educators to allocate time and energy in new directions. Key success factors likely include high intensity and duration, integration into career trajectories, integration into clinical programs, and activities to enfranchise institutional leadership.

The Next Accreditation System.

The Accreditation Council for Graduate Medical Education has implemented a new accreditation system for graduate medical education in the United States. This system, called the Next Accreditation System, focuses on more continuous monitoring of the outcomes of residency training, and for high-quality programs, less on the detailed processes of that training. This allows programs to innovate to best meet the needs of their trainees and communities. This new system also reviews the clinical learning environment at each institution sponsoring graduate medical education, focusing on professionalism, trainee supervision, duty hour and fatigue management, care transitions, and integration of residents into patient safety and health care quality. This Next Accreditation System is too new to fully assess its outcomes in better preparing residents for medical practice. Assessments of its early implementation, however, suggest we can expect such outcomes in the near future.

Enhancing self-efficacy and patient care with cardiovascular nutrition education.

BACKGROUND: Provision of medical education that develops nutrition knowledge and self-efficacy is critical if physicians are to incorporate nutrition in preventive care. We studied the impact of a cardiovascular nutrition module on the knowledge, attitudes, and self-efficacy of fourth-year medical students and the relationship of these attributes to patient care practices. METHODS: Based on national practice guidelines and learner needs, an educational intervention consisting of two web-based cases, pocket reference cards, and classroom discussion was developed and implemented. Knowledge, attitudes, and self-efficacy were measured at the beginning and end of the 4-week ambulatory care rotation for 40 control and 156 experimental students. Performance in patient care was approximated using a self-report; chart audits were performed for a subset of students. CONCLUSIONS: Knowledge scores of experimental students increased significantly from a mean of 10.3 to 14.4 (p<0.001), while the change for control students from 9.2 to 9.8 was not significant (p=0.20). The increase in self-efficacy scores from 26.2 to 35.7 in the experimental group (p<0.001) was twice that of the increase from 25.8 to 29.9 in the control group (p=0.001). Small but significant increases in attitude scores were similar for both groups. Limited data on student performance revealed that students with greater cardiovascular nutrition self-efficacy were more likely to address nutrition with cardiovascular patients. CONCLUSIONS: Incorporation of cardiovascular nutrition concepts in an ambulatory care rotation including use of computer-based cases improved student knowledge and self-efficacy, which may translate to increased frequency of future physicians addressing nutrition with patients.

What is a geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs end-of-training entrustable professional activities for geriatric medicine.

Entrustable professional activities (EPAs) describe the core work that constitutes a discipline's specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end-of-training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatrician's fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.

The Power of Collaboration: Experiences From the Educational Innovations Project and Implications for the Next Accreditation System.

BACKGROUND: The Internal Medicine Educational Innovations Project (EIP) is a 10-year pilot project for innovating in accreditation, which involves annual reporting of information and less-restrictive requirements for a group of high-performing programs. The EIP program directors' experiences offer insight into the benefits and challenges of innovative approaches to accreditation as the Accreditation Council for Graduate Medical Education transitions to the Next Accreditation System. OBJECTIVE: We assessed participating program directors' perceptions of the EIP at the midpoint of the project's 10-year life span. METHODS: We conducted telephone interviews with 15 of 18 current EIP programs (83% response rate) using a 19-item, open-ended, structured survey. Emerging themes were identified with content analysis. RESULTS: Respondents identified a number of the benefits from the EIP, most prominent among them, collaboration between programs (87%, 13 of 15) and culture change around quality improvement (47%, 7 of 15). The greatest benefit for residents was training in quality improvement methods (53%, 8 of 15), enhancing those residents' ability to become change agents in their future careers. Although the requirement for annual data reporting was identified by 60% (9 of 15) of program directors as the biggest challenge, respondents also considered it an important element for achieving progress on innovations. Program directors unanimously reported their ability to sustain innovation projects beyond the 10-year participation in EIP. CONCLUSIONS: The work of EIP was not viewed as "more work," but as "different work," which created a new mindset of continuous quality improvement in residency training. Lessons learned offer insight into the value of collaboration and opportunities to use accreditation to foster innovation.

The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine.

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep-ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.