The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education.

In 2010, several key works in medical education predicted the changes necessary to train modern physicians to meet current and future challenges in health care, including the standardization of learning outcomes paired with individualized learning processes. The reframing of a medical expert as a flexible, adaptive team member and change agent, effective within a larger system and responsive to the community's needs, requires a new approach to education: competency-based medical education (CBME). CBME is an outcomes-based developmental approach to ensuring each trainee's readiness to advance through stages of training and continue to grow in unsupervised practice. Implementation of CBME with fidelity is a complex and challenging endeavor, demanding a fundamental shift in organizational culture and investment in appropriate infrastructure. This paper outlines how member schools of the American Medical Association Accelerating Change in Medical Education Consortium developed and implemented CBME, including common challenges and successes. Critical supporting factors include adoption of the master adaptive learner construct, longitudinal views of learner development, coaching, and a supportive learning environment.

What can regulatory bodies do to help implement competency-based medical education?

In response to the numerous challenges resident trainees currently face in their ability to competently acquire the requisite skills, knowledge and attitudes upon graduation, medical educators have looked to a competency-based medical education (CBME) approach as a possible solution. As CBME has already been implemented in many jurisdictions around the world, certain challenges in implementation have been experienced. One important challenge identified relates to how regulatory bodies can either assist or unintentionally hinder implementation. By examining the varied experiences from Canada, the USA and the Netherlands in implementing CBME, this paper identifies how regulatory bodies can support and advance worldwide efforts of furthering its implementation. If regulatory bodies restructure accreditation and regulatory criteria to align with CBME principles, work together in a coordinated fashion to ensure alignment of vital regulatory meaures throughout the training and practice continuum of a physician, and allow for (if not incentivize) individuals and programs to be innovative in adapting CBME to meet their local environments, it is likely that the worldwide implementation of CBME will occur successfully.

Psychology and learning: The role of the clinical learning environment.

The clinical learning environment for the postgraduate education of physicians significantly influences the learning process and the outcomes of learning. Two critical aspects of the learning environment, when viewed through a psychology lens are (1) constructs from psychology relevant to learning, such as cognitive load theory and learner self-efficacy; and (2) psychological attributes of the context in which learning occurs such as psychological safety and "Just Culture". In this paper, we address selected psychological aspects of the clinical learning environment, with a particular focus on the establishment and sustainment of psychological safety in the clinical learning environment for physicians. Psychological safety is defined as individuals' perceptions that they can speak out in the learning or working context without consequences for their professional standing or risks to their status on work teams or groups. We close with seven critical strategies for use by educators, learners, health systems leaders, and other stakeholders to contribute to a clinical environment that optimizes learning. These dimensions can also provide avenues for future research to enhance the community's understanding of psychological constructs operating in the clinical learning environment.

The clinical learning environment.

Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. The subject of the clinical learning environment (CLE) is at the forefront of discussions. In this introduction to a themed issue on the CLE, we present an expanded conceptual model that approaches the CLE through six different lenses, termed "avenues:" architectural, digital, diversity and inclusion, education, psychological, and sociocultural, with each avenue represented by a paper. The aim is to facilitate dialog around the contributions of different academic disciplines to research on the CLE. Collectively the papers highlight the overlap between the various "avenues" in how they influence each other, and how they collectively have shaped the work to understand and improve the CLE. The expectation is that the various avenues can add to existing knowledge and create new ideas for interventions to improve the clinical learning environment across nations for learners and teachers with the ultimate aim of improving patient care. Research and efforts to improve the CLE are critical to learning, professional socialization and well-being for trainees as they learn and participate in patient care, and to the quality of care they will deliver over decades of practice after graduation.

Financing U.S. Graduate Medical Education: A Policy Position Paper of the Alliance for Academic Internal Medicine and the American College of Physicians.

In this position paper, the Alliance for Academic Internal Medicine and the American College of Physicians examine the state of graduate medical education (GME) financing in the United States and recent proposals to reform GME funding. They make a series of recommendations to reform the current funding system to better align GME with the needs of the nation's health care workforce. These recommendations include using Medicare GME funds to meet policy goals and to ensure an adequate supply of physicians, a proper specialty mix, and appropriate training sites; spreading the costs of financing GME across the health care system; evaluating the true cost of training a resident and establishing a single per-resident amount; increasing transparency and innovation; and ensuring that primary care residents receive training in well-functioning ambulatory settings that are financially supported for their training roles.

The Internal Medicine Reporting Milestones: Cross-sectional Description of Initial Implementation in U.S. Residency Programs.

BACKGROUND: High-quality assessment of resident performance is needed to guide individual residents' development and ensure their preparedness to provide patient care. To facilitate this aim, reporting milestones are now required across all internal medicine (IM) residency programs. OBJECTIVE: To describe initial milestone ratings for the population of IM residents by IM residency programs. DESIGN: Cross-sectional study. SETTING: IM residency programs. PARTICIPANTS: All IM residents whose residency program directors submitted milestone data at the end of the 2013-2014 academic year. MEASUREMENTS: Ratings addressed 6 competencies and 22 subcompetencies. A rating of "not assessable" indicated insufficient information to evaluate the given subcompetency. Descriptive statistics were calculated to describe ratings across competencies and training years. RESULTS: Data were available for all 21 774 U.S. IM residents from all 383 programs. Overall, 2889 residents (1621 in postgraduate year 1 [PGY-1], 902 in PGY-2, and 366 in PGY-3) had at least 1 subcompetency rated as not assessable. Summaries of average ratings by competency and training year showed higher ratings for PGY-3 residents in all competencies. Overall ratings for each of the 6 individual competencies showed that fewer than 1% of third-year residents were rated as "unsatisfactory" or "conditional on improvement." However, when subcompetency milestone ratings were used, 861 residents (12.8%) who successfully completed training had at least 1 competency with all corresponding subcompetencies graded below the threshold of "readiness for unsupervised practice." LIMITATION: Data were derived from a point in time in the first reporting period in which milestones were used. CONCLUSION: The initial milestone-based evaluations of IM residents nationally suggest that documenting developmental progression of competency is possible over training years. Subcompetencies may identify areas in which residents might benefit from additional feedback and experience. Future work is needed to explore how milestones are used to support residents' development and enhance residency curricula. PRIMARY FUNDING SOURCE: None.

Changing the culture of medical training: An important step toward the implementation of competency-based medical education.

OBJECTIVE: The current medical education system is steeped in tradition and has been shaped by many long-held beliefs and convictions about the essential components of training. The objective of this article is to propose initiatives to overcome biases against competency-based medical education (CBME) in the culture of medical education. MATERIALS AND METHODS: At a retreat of the International Competency Based Medical Education (ICBME) Collaborators group, an intensive brainstorming session was held to determine potential barriers to adoption of CBME in the culture of medical education. This was supplemented with a review of the literature on the topic. RESULTS: There continues to exist significant key barriers to the widespread adoption of CBME. Change in educational culture must be embraced by all components of the medical education hierarchy. Research is essential to provide convincing evidence of the benefit of CBME. CONCLUSIONS: The widespread adoption of CBME will require a change in the professional, institutional, and organizational culture surrounding the training of medical professionals.

Implementing competency-based medical education: What changes in curricular structure and processes are needed?

Medical educators must prepare for a number of challenges when they decide to implement a competency-based curriculum. Many of these challenges will pertain to three key aspects of implementation: organizing the structural changes that will be necessary to deliver new curricula and methods of assessment; modifying the processes of teaching and evaluation; and helping to change the culture of education so that the CBME paradigm gains acceptance. This paper focuses on nine key considerations that will support positive change in first two of these areas. Key considerations include: ensuring that educational continuity exists amongst all levels of medical education, altering how time is used in medical education, involving CBME in human health resources planning, ensuring that competent doctors work in competent health care systems, ensuring that information technology supports CBME, ensuring that faculty development is supported, ensuring that the rights and responsibilities of the learner are appropriately balanced in the workplace, preparing for the costs of change, and having appropriate leadership in order to achieve success in implementation.

Overarching challenges to the implementation of competency-based medical education.

Medical education is under increasing pressure to more effectively prepare physicians to meet the needs of patients and populations. With its emphasis on individual, programmatic, and institutional outcomes, competency-based medical education (CBME) has the potential to realign medical education with this societal expectation. Implementing CBME, however, comes with significant challenges. This manuscript describes four overarching challenges that must be confronted by medical educators worldwide in the implementation of CBME: (1) the need to align all regulatory stakeholders in order to facilitate the optimization of training programs and learning environments so that they support competency-based progression; (2) the purposeful integration of efforts to redesign both medical education and the delivery of clinical care; (3) the need to establish expected outcomes for individuals, programs, training institutions, and health care systems so that performance can be measured; and (4) the need to establish a culture of mutual accountability for the achievement of these defined outcomes. In overcoming these challenges, medical educators, leaders, and policy-makers will need to seek collaborative approaches to common problems and to learn from innovators who have already successfully made the transition to CBME.