Editor’s note: This is the second post in a series of posts related to CBME. Read the medical student perspective here. This post was written by a current Royal College EM trainee at Queen’s University who has a keen interest in education and who has been extensively involved in the transition to CBME locally and nationally.
Competency based medical education (CBME) – is it an ideology, an educational overhaul, or a make-work project from the higher ups? Intuitively, the idea of CBME makes sense to me. We are training to become excellent physicians and our training should be outcomes-based to track progress and ensure achievement of this goal. I see CBME as less of a true overhaul to PGME and more of an improvement in the process. As a resident at Queen’s University, I will be a part of the transition to CBME with the new residents starting July 2017. The following story is a description of what I envision a CBME experience in FRCPC Emergency Medicine (EM) could look like, from day one to successful FRCPC certification.
Meet Emily, an eager medical student accepted to the Queen’s EM program from her respected medical school. Emily moves across the country, showing up fresh and ready to go on July 1, 2017.
Transition to Discipline
The obligatory PGME orientation days come and go, leaving Emily feeling a little overwhelmed, but definitely ready to get back into the hospital and write her first prescription! On her first clinical day, the attending physician asks her what she would like to work on that shift. Emily is taken aback – ‘aren’t you supposed to tell me?’ she thinks, but instead takes the opportunity to ask for a direct observation of one of her Transition to Discipline entrustable professional activities (EPAs). Her attending happily agrees and half way through their 8-hour shift has a few minutes to listen in and observe a focused history and physical exam, filling out Emily’s assessment online as they go. Upon review, and as expected, Emily is not quite ready to be left to her own devices to handle this EPA and is given a ‘direct supervision’ score along with some written and verbal comments by her attending. It is only her first day after all. Emily leaves the encounter feeling encouraged with tools to improve for next time. Since the expectations were clearly laid out and specific, she feels that the feedback/coaching that she received was concrete and directly related to her performance in that specific encounter.
Emily’s first few months take place entirely in the ED, supplemented by weekly education sessions in the simulation lab – learning basic bedside ultrasound techniques and essential EM skills like intubation, procedural sedation, and chest tubes. Emily feels that she knows what will be coming and has a good idea of where she sits on her individualized learning plan that she co-created with her academic advisor in her first week as a resident. It helps that all she has to do is log on to the electronic portfolio system to track her progress and review all of the assessments she has completed thus far, including EPAs, OSCEs, written exams, and other required training experiences. She already has more than half of her bedside ultrasound scans that it will take to obtain competence!
Time is flying by, and the time has come for Emily to meet with her academic advisor to review her progress. It looks like she has gotten off to a great start and is integrating well into the EM residency program. Her academic advisor recommends her promotion to the Foundations stage, and this is approved by the EM Competence Committee after reviewing her complete file.
Foundations of the Discipline
Emily is now in the Foundations of Discipline stage and feeling increasingly comfortable seeing patients in the ER under indirect supervision. Most of Emily’s first year finds her in the ED, which has given her comfort and confidence in her abilities – she feels like a real ‘EM resident’ and has a better understanding of what she needs to take from her upcoming required training experiences on off-service rotations. Every quarter Emily reviews her training portfolio with her academic advisor, reflects on her aggregated performance, and modifies her personal learning plan to best meet her learning needs. This is also a great opportunity for Emily to explore career opportunities and engage in formal mentorship with an EM staff.
Core of Discipline
Within the year, Emily progresses on track with her peers to the next stage in EM training, Core of Discipline, which has a few off-service blocks to gain focused experiences. Based on normalized data comparing her performance to that of her peers, it is clear that Emily is exceeding expectations routinely and completing EPAs independently on a trajectory that is well above average. She has, however, seemed to lag behind in certain procedures such as chest tubes. It seems as though Emily has just not been exposed to very many while on shift. Emily brings this up with her academic advisor and they arrange a longitudinal half-day in the thoracic O.R. to make up for this gap. Emily soon becomes competent in that procedure, and on track to write her FRCP EM exam with the rest of her cohort at the end of their Core of Discipline stage. Two years of reading Rosen’s front to back and front again pays off and Emily passes the exam with her cohort.
Transition to Practice
The final stage, Transition to Practice, is the next step, during which Emily chooses to begin a Masters of Medical Education (MMEd) hoping to make some connections and gain essential skills to progress towards a career as an academic EM clinical educator and physician. At the same time, Emily decides to start a family with her partner while working towards her subspecialty of medical education and gaining skills to aid in the transition from learner to supervisor, ED manager, and attending physician. Her year is extended with a six-month maternity leave and she completes her FRCPC EM certification by the time her new daughter can walk! At the end of her training, Emily is not frightened of independent practice – she is excited to start working, feeling confident in her skills and ready to run her own ED. She is looking forward to finishing her MMEd and helping set up a new satellite campus for her medical school.
Looking back, Emily’s path doesn’t seem much different than that of a typical FRCPC EM resident today – and most of ours will not be. What is unique with CBME is the system’s built in flexibility and ability to cater to Emily’s needs as a learner. Looking forward, I hope that the new targeted assessments lead to specific and effective feedback on shift. I am eager to gain insight, formal mentorship, and career guidance from an academic advisor and the creation of an individualized learning plan. CBME is an outcomes-based, learner-centered educational model that moves the culture from one that is time-based and assumes learning, to one of competency-based deliberate practice everyday. I’m excited to see what CBME can do for me!