Competence By Design: a transformational national model of time-variable competency-based postgraduate medical education.

Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide.

Strategies to Enable Transformation in Medical Education: Faculty and Trainee Development in Competence By Design.

Transformative changes in health professions education need to incorporate effective faculty development, but few very large-scale faculty development designs have been described. The Royal College of Physicians and Surgeons of Canada's Competence by Design project was launched to transform the delivery of postgraduate medical education in Canada using a competency-based model. In this paper we outline the goals, principles, and rationale of the Royal College's national strategy for faculty and resident development initiatives to support the implementation of Competence by Design. We describe the activities and resources for both faculty and trainees that facilitated the redesign of training programs for each specialty and subspecialty at the national level, as well as supporting the implementation of the redesign at the local level. This undertaking was not without its challenges: we thus reflect on those challenges, enablers, and the lessons learned, and discuss a continuous quality improvement approach that was taken to iteratively inform the implementation process moving forward.

Challenges of implementing competency-based medical education postgraduate training programs: the issue of context / Desafíos de la implementación de programas de formación de posgrado en educación médica basada en competencias: la cuestión del contexto

Introduction: Competency-based medical education (CBME) is being adopted worldwide. The aim of this paper is to discuss the evolution of CBME and address some perceived challenges in CBME curriculum development and implementation in postgraduate (residency) medical education. Methods: This is an opinion paper based on lived experiences and personal beliefs. The authors have professional training in medical education and are actively involved in CBME research, curriculum development and implementation around the world. Results: The issue of local and system-wide context seems to be of particular importance to individuals, programs, institutions, governing bodies and other stakeholders involved in the development and implementation of CBME programs. CBME has evolved differently at different places, and there are concerns regarding the fidelity of implementation. Stakeholders have been dealing with challenging questions in their CBME journeys, which reflect the varied, complex and dynamic nature of health and education systems. Recently, scholars have established core components of any CBME program. Discussion and conclusions: CBME design should benefit from ground-up strategies that consider the local context. It is essential to approach implementation with a quality improvement lens and pay special attention to the fidelity and integrity of the core CBME components.

Introducción: la educación médica basada en competencias (CBME) se está adoptando en todo el mundo. El objetivo de este artículo es discutir la evolución de la CBME y abordar algunos desafíos percibidos en el desarrollo y la implementación de los estándares de CBME en la educación médica de posgrado (residencia). Métodos: este es un artículo de opinión basado en experiencias vividas y creencias personales. Los autores tienen formación profesional en educación médica y participan activamente en la investigación, el desarrollo y la implementación de programas de CBME en varios países. Resultados: la cuestión del contexto local y de todo el sistema parece ser de particular importancia para las personas, los programas, las instituciones, los órganos de gobierno y otras partes inte-resadas involucradas en el desarrollo y la implementación de los programas de CBME. La CBME ha evolucionado de manera diferente en diferentes lugares y existen preocupaciones con respecto a la fidelidad de la implementación. Las partes interesadas han estado lidiando con cuestiones difíciles en sus proyectos de CBME, que reflejan la naturaleza variada, compleja y dinámica de los sistemas de salud y educación. Recientemente, los académicos han establecido componentes centrales de cualquier programa CBME. Discusión y conclusiones: el diseño de la CBME debería beneficiarse de estrategias de base que consideren el contexto local. Sin embargo, es importante abordar la implementación con una lente de mejora de la calidad y prestar especial atención a la fidelidad e integridad de los componentes centrales de la CBME.

Questioning medical competence: Should the Covid-19 crisis affect the goals of medical education?

The COVID-19 pandemic has disrupted many societal institutions, including health care and education. Although the pandemic's impact was initially assumed to be temporary, there is growing conviction that medical education might change more permanently. The International Competency-based Medical Education (ICBME) collaborators, scholars devoted to improving physician training, deliberated how the pandemic raises questions about medical competence. We formulated 12 broad-reaching issues for discussion, grouped into micro-, meso-, and macro-level questions. At the individual micro level, we ask questions about adaptability, coping with uncertainty, and the value and limitations of clinical courage. At the institutional meso level, we question whether curricula could include more than core entrustable professional activities (EPAs) and focus on individualized, dynamic, and adaptable portfolios of EPAs that, at any moment, reflect current competence and preparedness for disasters. At the regulatory and societal macro level, should conditions for licensing be reconsidered? Should rules of liability be adapted to match the need for rapid redeployment? We do not propose a blueprint for the future of medical training but rather aim to provoke discussions needed to build a workforce that is competent to cope with future health care crises.

Evaluating a novel resident role-modelling programme.

BACKGROUND: Role modelling is a fundamental method by which students learn from residents. To our knowledge, however, resident-as-teacher curricula have not explicitly addressed resident role modelling. The purpose of this project was to design, implement and evaluate an innovative programme to teach residents about role modelling. METHODS: The authors designed a resident role-modelling programme and incorporated it into the 2015 and 2016 McGill University resident-as-teacher curriculum. Influenced by experiential and social learning theories, the programme incorporated flipped-classroom and simulation approaches to teach residents to be aware and deliberate role models. Outcomes were assessed through a pre- and immediate post-programme questionnaire evaluating reaction and learning, a delayed post-programme questionnaire evaluating learning, and a retrospective pre-post questionnaire (1 month following the programme) evaluating self-reported behaviour changes. RESULTS: Thirty-three of 38 (87%) residents who participated in the programme completed the evaluation, with 25 residents (66%) completing all questionnaires. Participants rated the programme highly on a five-point Likert scale (where 1 = not helpful and 5 = very helpful; mean score, M = 4.57; standard deviation, SD = 0.50), and showed significant improvement in their perceptions of their importance as role models and their knowledge of deliberate role modelling. Residents also reported an increased use of deliberate role-modelling strategies 1 month after completing the programme. Resident-as-teacher curricula have not explicitly addressed resident role modelling DISCUSSION: The incorporation of resident role modelling into our resident-as-teacher curriculum positively influenced the participants' perceptions of their role-modelling abilities. This programme responds to a gap in resident training and has the potential to guide further programme development in this important and often overlooked area.

EQual, a Novel Rubric to Evaluate Entrustable Professional Activities for Quality and Structure.

PURPOSE: Entrustable professional activities (EPAs) have become a cornerstone of assessment in competency-based medical education (CBME). Increasingly, EPAs are being adopted that do not conform to EPA standards. This study aimed to develop and validate a scoring rubric to evaluate EPAs for alignment with their purpose, and to identify substandard EPAs. METHOD: The EQual rubric was developed and revised by a team of education scholars with expertise in EPAs. It was then applied by four residency program directors/CBME leads (PDs) and four nonclinician support staff to 31 stage-specific EPAs developed for internal medicine in the Royal College of Physicians and Surgeons of Canada's Competency by Design framework. Results were analyzed using a generalizability study to evaluate overall reliability, with the EPAs as the object of measurement. Item-level analysis was performed to determine reliability and discrimination value for each item. Scores from the PDs were also compared with decisions about revisions made independently by the education scholars group. RESULTS: The EQual rubric demonstrated high reliability in the G-study with a phi-coefficient of 0.84 when applied by the PDs, and moderate reliability when applied by the support staff at 0.67. Item-level analysis identified three items that performed poorly with low item discrimination and low interrater reliability indices. Scores from support staff only moderately correlated with PDs. Using the preestablished cut score, PDs identified 9 of 10 EPAs deemed to require major revision. CONCLUSIONS: EQual rubric scores reliably measured alignment of EPAs with literature-described standards. Further, its application accurately identified EPAs requiring major revisions.

Advancing Competency-Based Medical Education: A Charter for Clinician-Educators.

The International Competency-Based Medical Education (ICBME) Collaborators have been working since 2009 to promote understanding of competency-based medical education (CBME) and accelerate its uptake worldwide. This article presents a charter, supported by a literature-based rationale, which is meant to provide a shared mental model of CBME that will serve as a path forward in its widespread implementation.At a 2013 summit, the ICBME Collaborators laid the groundwork for this charter. Here, the fundamental principles of CBME and professional responsibilities of medical educators in its implementation process are described. The authors outline three fundamental principles: (1) Medical education must be based on the health needs of the populations served; (2) the primary focus of education and training should be the desired outcomes for learners rather than the structure and process of the educational system; and (3) the formation of a physician should be seamless across the continuum of education, training, and practice.Building on these principles, medical educators must demonstrate commitment to teaching, assessing, and role modeling the range of identified competencies. In the clinical setting, they must provide supervision that balances patient safety with the professional development of learners, being transparent with stakeholders about level of supervision needed. They must use effective and efficient assessment strategies and tools for basing transition decisions on competence rather than time in training, empowering learners to be active participants in their learning and assessment. Finally, advancing CBME requires program evaluation and research, faculty development, and a collaborative approach to realize its full potential.

Entrustment Decision Making in Clinical Training.

The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.

Competency-based medical education: theory to practice.

Although competency-based medical education (CBME) has attracted renewed interest in recent years among educators and policy-makers in the health care professions, there is little agreement on many aspects of this paradigm. We convened a unique partnership - the International CBME Collaborators - to examine conceptual issues and current debates in CBME. We engaged in a multi-stage group process and held a consensus conference with the aim of reviewing the scholarly literature of competency-based medical education, identifying controversies in need of clarification, proposing definitions and concepts that could be useful to educators across many jurisdictions, and exploring future directions for this approach to preparing health professionals. In this paper, we describe the evolution of CBME from the outcomes movement in the 20th century to a renewed approach that, focused on accountability and curricular outcomes and organized around competencies, promotes greater learner-centredness and de-emphasizes time-based curricular design. In this paradigm, competence and related terms are redefined to emphasize their multi-dimensional, dynamic, developmental, and contextual nature. CBME therefore has significant implications for the planning of medical curricula and will have an important impact in reshaping the enterprise of medical education. We elaborate on this emerging CBME approach and its related concepts, and invite medical educators everywhere to enter into further dialogue about the promise and the potential perils of competency-based medical curricula for the 21st century.