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.

Competency-Based Medical Education at Scale: A Road Map for Transforming National Systems of Postgraduate Medical Education.

In the past decade, the Canadian system of postgraduate medical education has been transformed with the implementation of a new approach to competency based medical education called Competence by Design. The Royal College of Physicians and Surgeons of Canada (Royal College) developed an approach to time-variable competency based medical education and adapted that design for medical, surgical, and diagnostic disciplines. New educational standards and entrustable professional activities consistent with this approach were co-created with 67 specialties and subspecialties, and implementation was scaled up across 17 universities and over 1000 postgraduate training programs. Partner engagement, systematic design of workshops to create discipline specific competency-based standards of education, and agile adaptation were all key ingredients for success. This paper describes the strategies applied by the Royal College, lessons learned regarding transformative change in the complex system of postgraduate medical education, and the current status of the Competence by Design initiative. The approach taken and lessons learned by the Royal College may be useful for other educators who are planning a transformation to CBME or any other major educational reform.

Implementing Competence Committees on a National Scale: Design and Lessons Learned.

Competence committees (CCs) are a recent innovation to improve assessment decision-making in health professions education. CCs enable a group of trained, dedicated educators to review a portfolio of observations about a learner's progress toward competence and make systematic assessment decisions. CCs are aligned with competency based medical education (CBME) and programmatic assessment. While there is an emerging literature on CCs, little has been published on their system-wide implementation. National-scale implementation of CCs is complex, owing to the culture change that underlies this shift in assessment paradigm and the logistics and skills needed to enable it. We present the Royal College of Physicians and Surgeons of Canada's experience implementing a national CC model, the challenges the Royal College faced, and some strategies to address them. With large scale CC implementation, managing the tension between standardization and flexibility is a fundamental issue that needs to be anticipated and addressed, with careful consideration of individual program needs, resources, and engagement of invested groups. If implementation is to take place in a wide variety of contexts, an approach that uses multiple engagement and communication strategies to allow for local adaptations is needed. Large-scale implementation of CCs, like any transformative initiative, does not occur at a single point but is an evolutionary process requiring both upfront resources and ongoing support. As such, it is important to consider embedding a plan for program evaluation at the outset. We hope these shared lessons will be of value to other educators who are considering a large-scale CBME CC implementation.

Evaluating Competence by Design as a Large System Change Initiative: Readiness, Fidelity, and Outcomes.

Program evaluation is an essential, but often neglected, activity in any transformational educational change. Competence by Design was a large-scale change initiative to implement a competency-based time-variable educational system in Canadian postgraduate medical education. A program evaluation strategy was an integral part of the build and implementation plan for CBD from the beginning, providing insights into implementation progress, challenges, unexpected outcomes, and impact. The Competence by Design program evaluation strategy was built upon a logic model and three pillars of evaluation: readiness to implement, fidelity and integrity of implementation, and outcomes of implementation. The program evaluation strategy harvested from both internally driven studies and those performed by partners and invested others. A dashboard for the program evaluation strategy was created to transparently display a real-time view of Competence by Design implementation and facilitate continuous adaptation and improvement. The findings of the program evaluation for Competence by Design drove changes to all aspects of the Competence by Design implementation, aided engagement of partners, supported change management, and deepened our understanding of the journey required for transformational educational change in a complex national postgraduate medical education system. The program evaluation strategy for Competence by Design provides a framework for program evaluation for any large-scale change in health professions education.

Coaching in Competence by Design: A New Model of Coaching in the Moment and Coaching Over Time to Support Large Scale Implementation.

Coaching is an increasingly popular means to provide individualized, learner-centered, developmental guidance to trainees in competency based medical education (CBME) curricula. Aligned with CBME's core components, coaching can assist in leveraging the full potential of this educational approach. With its focus on growth and improvement, coaching helps trainees develop clinical acumen and self-regulated learning skills. Developing a shared mental model for coaching in the medical education context is crucial to facilitate integration and subsequent evaluation of success. This paper describes the Royal College of Physicians and Surgeons of Canada's coaching model, one that is theory based, evidence informed, principle driven and iteratively and developed by a multidisciplinary team. The coaching model was specifically designed, fit for purpose to the postgraduate medical education (PGME) context and implemented as part of Competence by Design (CBD), a new competency based PGME program. This coaching model differentiates two coaching roles, which reflect different contexts in which postgraduate trainees learn and develop skills. Both roles are supported by the RX-OCR process: developing Relationship/Rapport, setting eXpectations, Observing, a Coaching conversation, and Recording/Reflecting. The CBD Coaching Model and its associated RX-OCR faculty development tool support the implementation of coaching in CBME. Coaching in the moment and coaching over time offer important mechanisms by which CBD brings value to trainees. For sustained change to occur and for learners and coaches to experience the model's intended benefits, ongoing professional development efforts are needed. Early post implementation reflections and lessons learned are provided.

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.

Exploring the Quality of Feedback in Entrustable Professional Activity Narratives Across 24 Residency Training Programs.

Background Competency-based medical education (CBME) has been implemented in many residency training programs across Canada. A key component of CBME is documentation of frequent low-stakes workplace-based assessments to track trainee progression over time. Critically, the quality of narrative feedback is imperative for trainees to accumulate a body of evidence of their progress. Suboptimal narrative feedback will challenge accurate decision-making, such as promotion to the next stage of training. Objective To explore the quality of documented feedback provided on workplace-based assessments by examining and scoring narrative comments using a published quality scoring framework. Methods We employed a retrospective cohort secondary analysis of existing data using a sample of 25% of entrustable professional activity (EPA) observations from trainee portfolios from 24 programs in one institution in Canada from July 2019 to June 2020. Statistical analyses explore the variance of scores between programs (Kruskal-Wallis rank sum test) and potential associations between program size, CBME launch year, and medical versus surgical specialties (Spearman's rho). Results Mean quality scores of 5681 narrative comments ranged from 2.0±1.2 to 3.4±1.4 out of 5 across programs. A significant and moderate difference in the quality of feedback across programs was identified (χ2=321.38, P<.001, ε2=0.06). Smaller programs and those with an earlier launch year performed better (P<.001). No significant difference was found in quality score when comparing surgical/procedural and medical programs that transitioned to CBME in this institution (P=.65). Conclusions This study illustrates the complexity of examining the quality of narrative comments provided to trainees through EPA assessments.

Helicobacter pylori induces a novel form of innate immune memory via accumulation of NF-кB proteins.

Helicobacter pylori is a widespread Gram-negative pathogen involved in a variety of gastrointestinal diseases, including gastritis, ulceration, mucosa-associated lymphoid tissue (MALT) lymphoma and gastric cancer. Immune responses aimed at eradication of H. pylori often prove futile, and paradoxically play a crucial role in the degeneration of epithelial integrity and disease progression. We have previously shown that H. pylori infection of primary human monocytes increases their potential to respond to subsequent bacterial stimuli - a process that may be involved in the generation of exaggerated, yet ineffective immune responses directed against the pathogen. In this study, we show that H. pylori-induced monocyte priming is not a common feature of Gram-negative bacteria, as Acinetobacter lwoffii induces tolerance to subsequent Escherichia coli lipopolysaccharide (LPS) challenge. Although the increased reactivity of H. pylori-infected monocytes seems to be specific to H. pylori, it appears to be independent of its virulence factors Cag pathogenicity island (CagPAI), cytotoxin associated gene A (CagA), vacuolating toxin A (VacA) and γ-glutamyl transferase (γ-GT). Utilizing whole-cell proteomics complemented with biochemical signaling studies, we show that H. pylori infection of monocytes induces a unique proteomic signature compared to other pro-inflammatory priming stimuli, namely LPS and the pathobiont A. lwoffii. Contrary to these tolerance-inducing stimuli, H. pylori priming leads to accumulation of NF-кB proteins, including p65/RelA, and thus to the acquisition of a monocyte phenotype more responsive to subsequent LPS challenge. The plasticity of pro-inflammatory responses based on abundance and availability of intracellular signaling molecules may be a heretofore underappreciated form of regulating innate immune memory as well as a novel facet of the pathobiology induced by H. pylori.

Making sense of competency-based medical education (CBME) literary conversations: A BEME scoping review: BEME Guide No. 78.

BACKGROUND: Competency-based medical education (CBME) received increased attention in the early 2000s by educators, clinicians, and policy makers as a way to address concerns about physician preparedness and patient safety in a rapidly changing healthcare environment. Opinions and perspectives around this shift in medical education vary and, to date, a systematic search and synthesis of the literature has yet to be undertaken. The aim of this scoping review is to present a comprehensive map of the literary conversations surrounding CBME. METHODS: Twelve different databases were searched from database inception up until 29 April 2020. Literary conversations were extracted into the following categories: perceived advantages, perceived disadvantages, challenges/uncertainties/skepticism, and recommendations related to CBME. RESULTS: Of the 5757 identified records, 387 were included in this review. Through thematic analysis, eight themes were identified in the literary conversations about CBME: credibility, application, community influence, learner impact, assessment, educational developments, organizational structures, and societal impacts of CBME. Content analysis supported the development of a heat map that provides a visual illustration of the frequency of these literary conversations over time. CONCLUSIONS: This review serves two purposes for the medical education research community. First, this review acts as a comprehensive historical record of the shifting perceptions of CBME as the construct was introduced and adopted by many groups in the medical education global community over time. Second, this review consolidates the many literary conversations about CBME that followed the initial proposal for this approach. These findings can facilitate understanding of CBME for multiple audiences both within and outside of the medical education research community.

Ready, set, go! Evaluating readiness to implement competency-based medical education.

PURPOSE: Organizational readiness is critical for successful implementation of an innovation. We evaluated program readiness to implement Competence by Design (CBD), a model of Competency-Based Medical Education (CBME), among Canadian postgraduate training programs. METHODS: A survey of program directors was distributed 1 month prior to CBD implementation in 2019. Questions were informed by the R = MC2 framework of organizational readiness and addressed: program motivation, general capacity for change, and innovation-specific capacity. An overall readiness score was calculated. An ANOVA was conducted to compare overall readiness between disciplines. RESULTS: Survey response rate was 42% (n = 79). The mean overall readiness score was 74% (30-98%). There was no difference in scores between disciplines. The majority of respondents agreed that successful implementation of CBD was a priority (74%), and that their leadership (94%) and faculty and residents (87%) were supportive of change. Fewer perceived that CBD was a move in the right direction (58%) and that implementation was a manageable change (53%). Curriculum mapping, competence committees and programmatic assessment activities were completed by >90% of programs, while <50% had engaged off-service disciplines. CONCLUSION: Our study highlights important areas where programs excelled in their preparation for CBD, as well as common challenges that serve as targets for future intervention to improve program readiness for CBD implementation.

Implementation of competence committees during the transition to CBME in Canada: A national fidelity-focused evaluation.

PURPOSE: This study evaluated the fidelity of competence committee (CC) implementation in Canadian postgraduate specialist training programs during the transition to competency-based medical education (CBME). METHODS: A national survey of CC chairs was distributed to all CBME training programs in November 2019. Survey questions were derived from guiding documents published by the Royal College of Physicians and Surgeons of Canada reflecting intended processes and design. RESULTS: Response rate was 39% (113/293) with representation from all eligible disciplines. Committee size ranged from 3 to 20 members, 42% of programs included external members, and 20% included a resident representative. Most programs (72%) reported that a primary review and synthesis of resident assessment data occurs prior to the meeting, with some data reviewed collectively during meetings. When determining entrustable professional activity (EPA) achievement, most programs followed the national specialty guidelines closely with some exceptions (53%). Documented concerns about professionalism, EPA narrative comments, and EPA entrustment scores were most highly weighted when determining resident progress decisions. CONCLUSIONS: Heterogeneity in CC implementation likely reflects local adaptations, but may also explain some of the variable challenges faced by programs during the transition to CBME. Our results offer educational leaders important fidelity data that can help inform the larger evaluation and transformation of CBME.

Learner Phenotypes in Competency-Based Medical Education.

With the launch of competency-based medical education internationally, the practical realities of implementation have failed to live up to many of the proposed theoretical benefits. Specifically, as educators we have observed a number of assessment challenges that seem directly related to identified learner phenotypes. This commentary seeks to describe these specific learner phenotypes, along with actionable recommendations for programs and their competence committees in order to overcome the associated obstacles in assessment. We describe strategies related to both the individual and program level, which can be utilized for both short-term adjustments and long-term programmatic transformation.

Key considerations in planning and designing programmatic assessment in competency-based medical education.

Programmatic assessment as a concept is still novel for many in clinical education, and there may be a disconnect between the academics who publish about programmatic assessment and the front-line clinical educators who must put theory into practice. In this paper, we clearly define programmatic assessment and present high-level guidelines about its implementation in competency-based medical education (CBME) programs. The guidelines are informed by literature and by lessons learned from established programmatic assessment approaches. We articulate five steps to consider when implementing programmatic assessment in CBME contexts: articulate the purpose of the program of assessment, determine what must be assessed, choose tools fit for purpose, consider the stakes of assessments, and define processes for interpreting assessment data. In the process, we seek to offer a helpful guide or template for front-line clinical educators. We dispel some myths about programmatic assessment to help training programs as they look to design-or redesign-programs of assessment. In particular, we highlight the notion that programmatic assessment is not 'one size fits all'; rather, it is a system of assessment that results when shared common principles are considered and applied by individual programs as they plan and design their own bespoke model of programmatic assessment for CBME in their unique context.

Diagnosing conflict: Conflicting data, interpersonal conflict, and conflicts of interest in clinical competency committees.

Clinical competency committees (CCCs) are increasingly used within health professions education as their decisions are thought to be more defensible and fairer than those generated by previous training promotion processes. However, as with most group-based processes, it is inevitable that conflict will arise. In this paper the authors explore three ways conflict may arise within a CCC: (1) conflicting data submissions that are presented to the committee, (2) conflicts between members of the committee, and (3) conflicts of interest between a specific committee member and a trainee. The authors describe each of these conflict situations, dissect out the underlying problems, and explore possible solutions based on the current literature.

Twelve tips for learners to succeed in a CBME program.

The international movement to competency-based medical education (CBME) marks a major transition in medical education that requires a shift in educators' and learners' approach to clinical experiences, the way assessment data are collected and integrated, and in learners' mindsets. Learners entering a CBME curriculum must actively drive their learning experiences and education goals. For some, this expectation may be a significant change from their previous approach to learning in medicine. This paper highlights 12 tips to help learners succeed within a CBME model.