If I had a dollar for every time somebody mentioned Competency Based Medical Education (CBME), I could forget about the Royal College exam next year, and find a nice island to settle down on. Since nobody seems willing to contribute to my retirement fund, I am instead left wondering what CBME really is. It seemingly has become a buzz word amongst the medical education community, but many outside of this bubble (including myself) may have a very limited grasp or understanding of what the future of medical education is going to look like.
We dug through the plethora of resources available from the Royal College of Physicians and Surgeons, and garnered some insight from an leading expert, Dr. Jason Frank, the Director of Specialty Education and the lead of the Competency by Design (CBD) program, to help provide some further insight into what CBME will entail for educators and learners within medicine, and how to prepare for this paradigm shift.
Why do we need CBME?
Historically, residency education has been centred around a time based learning model, where participating in a particular number of cases, surgeries or years of training will allow one to reach an appropriate level of competence to practice alone (which has been the presumption for the past 100 years). By their own dereliction, the Royal College of Physicians and Surgeons has identified that while this system has, and continues to produce excellent physicians, that there is emerging evidence suggesting training methods may be improved. This conclusion is further supported by the culmination of medical education literature, decreasing resident work hours, patient safety initiatives that are limiting procedures and exposure, the ever expanding body of medical knowledge within each specialty, and higher societal expectations to demonstrate the development of higher competence standards [1-3].
CBME was thus borne out of a need to emphasize an outcomes-based approach to medical education. The construct for CBME relies on four foundations; focusing education on patient outcomes, emphasizing learner abilities, de-emphasizing time based learning and increasing individualized trainee plans for the learner .
Components of CBME
This is an excellent sounding framework, but what does it really mean? Instead of assuming that a learner is competent to practice independently after having completed their training, CBME focuses on a reconstructed system of assessment that allows significantly greater and more systematic learner assessments to more completely target their individual education needs based on their ongoing performance.
Typically we associated competence with the ability to practice independently, but this is a rather arbitrary static construct . With CBME, competence comes with modifiers that specify stage of training, context and in which domains this ability corresponds to. Within each of these domains/stages of training, a learner can achieve a level of competence from novice to master .
The Royal College is implementing CBME in Canada through the Competency by Design (CBD) initiative, in which they are formally transforming the approach to postgraduate medical within all specialties across Canada, utilizing the updated CanMEDS framework and the newly created competency continuum as a guide .
The components of CBME will be based upon “Entrustable Professional Activities” (EPA’s), which are specific “units of work” within that specialty that can be broken down into milestones and discreetly separated by residency stage. The implication of an “entrustable” activity, is to determine which functional tasks can supervising physicians trust a trainee to perform (and/or delegate) without direct supervision. For example, running a polytrauma resuscitation would be a high level EPA with multiple components with numerous skills that require high degrees of mastery. To be entrusted for that EPA (polytrauma resuscitation), a resident must have achieved a high degree of mastery for the component skills to act without direct supervision. If a resident is having difficulty with a particular EPA, the CBD framework allows the supervising physician to “break down” that trauma EPA into its component pieces, identify the skills lacking, and focus on the necessary milestones needed to establish a path for success .
Each specialty will have a range of 30 to 50 EPA’s across four stages of competency, with very specific components, rather than a global assessment. For example, an EPA may involve communication, and at each level of competency there are specific abilities the learner should demonstrate.
Currently, these EPA’s are “under construction” for Emergency Medicine across the country, and this is occurring within the Royal College specialty committee cohort process. This committee consists of all program directors across the country, CBME site leads, and a handful of other CBME experts and former EM specialty committee chairs. The process of creating new CBME curricular documents is an iterative one and involves bi-annual three day workshops at the Royal College and frequent working group teleconferences on an almost monthly basis. At the completion of the CBD EM cohort, our specialty will have a universal path for CBME across the country.
Each specialty has a different time line for the rollout of CBME, and for Emergency Medicine it’s first impact will be felt with the PGY-1 cohort in July 2018, with a grandfathered approach (ie: those already in programs will not operate with the CBME curricular format, but will have access to many of its new features including the use of innovative assessment systems, ePortfolios, and academic advisors). Other specialties have already begun to rollout CBME, and many will continue to do so, providing us with further experiences and evaluations.
The implementation of CBME will influence all levels of care within an academic centre, as there will be an enhanced emphasis on medical staff, allied health care professionals, patients and family members providing observational and more directive feedback. From an Emergency Medicine standpoint, we are well suited to embrace this change by the nature of supervising EM physicians having multiple opportunities to engage in direct observation of their residents. Currently, supervising physicians spend time filling out an evaluation or performance card. That time will ultimately be repurposed into witnessing an aspect of the resident’s care, and utilizing that to reflect upon the learner’s evaluation.
Learners often consider that CBME provides the opportunity to complete their residency within a shorter time course, but an important acknowledgement is that the time taken to complete their training will not change for the vast majority of residents. The experience around the world thus far suggests that a very small minority of residents would be considered exceptional, having completed their certification exam and all of their EPAs early, and allowed to graduate from their specialty residency programs early . On the flip side, for any trainees who are having difficulty, the new CBME system offers a way to identify trainees earlier in their residencies, better identify the specific areas (“building block skills/milestones”) they need to spend more time working on, and in the end help keep them on track for graduating in the expected five year time frame. In regards to the examination, this will likely take place at the end of the 4th year of training, with the 5th year of residency devoted to developing the transition to practice.
How can we prepare for CBME?
Knowing that CBME is coming, what can programs begin to do to prepare and anticipate the educational changes? Perhaps the highest yield proactive paradigm shift rests in how we currently evaluate learners. As discussed above, our current method for evaluating residents is not as good as it could be, and as such CBME is going to emphasize increased observational and multi-source assessments. This may take the form of observing a learner taking a chest pain history early in residency, running a resuscitation in the later stages of residency, or performing a procedure at any time throughout residency. These may be accomplished by informing the resident that you are going to perform an observed assessment (although, this can be awkward, and may introduce bias in the form of the Hawthorne effect). Alternatively, one may observe/listen to the resident when they are not aware they are being assessed (ie: “behind the curtain”). A lot can be garnered from these interactions, and one may be able to provide some higher yield feedback to the learner in various domains. Another new strategy is to engage the allied health care professionals, patients and family members that surround us and work with us while we provide care. Adopting new types of multi-source feedback can strengthen how we assess many of the CanMEDS roles beyond just the medical expert role, such as communication, health advocacy, professionalism, and leader.
While various EPA’s and assessment systems are being discussed at the Royal College level, introducing new assessment strategies and tools are simple changes that departments/faculty can initiate to assess residents, and utilize those assessments as the basis for that learner’s evaluation.
For senior residents, this is also an important consideration, as we will be responsible for supervising junior physicians in training, and we will be expected to engage in observational assessments of our learners. Since senior residents are often assessing junior residents/learners already, this is an excellent opportunity to practice and harness these skill sets before having to implement them for when we become faculty attending physicians ourselves.
As with the implementation of anything novel in medicine there are many anticipated challenges, the first of which is the logistical chaos inherent with changes to the system. As with change to any system, there will be many who want to maintain the status quo, and those who feel that change will require an excessive amount of work. There is some concern that the “reductionism” approach to medical education (ie: breaking down competencies into observable milestones) may create endless lists and goals, resulting in participant fatigue and frustration. Additionally, there is some fear that by targeting milestones, learners may perceive that these tasks are all that are required in their training, rather than striving for excellence .
It is not yet immediately clear what will happen to the sub-specialty training areas (niche areas) of Emergency Medicine, and whether these will remain a component of Royal College training, or if these will be pushed to the period after residency is completed (ie. Post-residency fellowships).
Upon the implementation of any new learning tool or curricular change, there needs to be a process of quality feedback. This includes planning, execution, monitoring, and evaluation, followed by resetting goals. Success will be absolutely tied to CBME being extensively studied; with ongoing monitoring and program evaluation to provide important feedback loops, accreditation to monitor the resident experience and setting standards for institutions to follow. The need for studying short term outcomes, and an extensive examination of long term outcomes (similar to studies such as Framingham) to see how participants are doing in their postgraduate years cannot be understated. Will this new model of CBME will effective? Will it be worth all the change required to make it happen? Will our patients be better off for this new approach to residency training? Studying these questions is essential.
Postgraduate medical education is embarking on transformative change in the coming years, and no specialty will be immune to its effects. Early evidence suggests that CBME may lead to better residency education, enhanced promotion of continuous medical education once in practice, and ultimately better care for our patients. The best way we can ensure that we are prepared for the change that is upon us, is to be aware of what is coming, understand the basis for why the change is happening, and become early adopters so that we can help shape CBME implementation in the future. A good place to start is with improving our observational assessments within our own programs to help ensure the highest quality training and feedback for our residents, and amongst our residency programs.
Stay tubed for a follow-up piece on CanadiEM regarding an exciting CBME pilot project in EM going on at one of our Canadian institutions!
Post peer reviewed and edit by Dr. Damon Dagnone (MD, MSc, FRCPC, MMEd, CBME Faculty Lead, Postgraduate Medical Education, Associate Professor in the Department of Emergency Medicine at Queen’s University, @Damonjdd1).
With special thanks to Dr. Jason Frank (MD, MA (Ed), FRCPC, Director of Speciality Education and the lead of the Competency by Design program) for taking the time to help provide some excellent insight. We welcome your comments below![bg_faq_start]
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