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C BME

COMPETENCY BASED MEDICAL EDUCATION


PERIE ADORABLE-WAGAN

SKILLS VALUES

KNOWLEDGE ATTITUDE
Objectives
1. Definition of Competency based
medical education (CBME)

RATIONALE 2. Origins of Competency based


ORIGINS medical education
ELEMENTS
3. Rationale of CBME
PRACTICAL
DEFINITION
4. Elements of planning
IMPLICATIONS

5. Practical implications of the CBME


approach across the continuum of
medical education.

Frank, J., Holmboe, E., Caraccio,C. CBME theory to practice, 2010; 32: 638645
CBME: Not a new concept

Flexner US OFFICE
OF EDUCATION
NATIONAL CENTER
Industry and FOR EDUCATION
business
looking for Reform of Vocational Medicine
workforce with teacher education late to
specific skills education concept

1968

1920s 1970s
What is Competency
Based Medical Education?
(CBME)
CBME : Not a new concept

Origins began around the time of Flexner (1910-1920)


Industry and business looking for workforce with specific skills
Modern impetus
Reform of teacher education in 1960s
US Office of Education National Center for Education research
grant program
Vocational education in 1970s onward
Medicine late to concept

CBME, Holmboe,E
Early Principles: CBME

World Health Organization (1978):

The intended output of competency-based


programme is a health professional who can practice
medicine at a defined level of proficiency in accord
with local conditions , and meet local needs

McGaghie WC., Miller GE, Sajid AW. Competency based Curriculum development in
medical education. WHO, Switzerland, 1978
Early Principles: CBME

2002 review, Carraccio and colleagues


explored competency-based models in the 1970s
no comparisons between competency-based and the
traditional structure/process-based curricula were undertaken.
of the few studies showed there appear to be some benefits to
learners in the CBME model.
Overview: Competency-based Medical Education (CBME)

AKA as Competency-based education and training (CBET), a term


transformed to CBME in medicine.
What is CBET? As Sullivan notes (1995):
In a traditional educational system, the unit of progression is
time and it is teacher-centered.
In a CBET system, the unit of progression is mastery of specific
knowledge and skills and is learner-centered.

Frank, JR. Snell LS, ten Cate O, et al. Competency based medical education: theory to practice.
Med Teach 2010: 32: 638-645
Competency based medical education

It is an outcome based approach to design, implement, assess and


evaluate medical educational program using an organizing
framework of competencies.

The unit of progression is mastery of specific knowledge, skills and


attitudes.

Frank, JR. Snell LS, ten Cate O, et al. Competency based medical education: theory to practice.
Med Teach 2010: 32: 638-645
DEFINITION
COMPETENCY
An observable ability KNOWLEDGE

SKILLS

COMPETENCY
VALUES

ATTITUDES

Frank, J., Holmboe, E., Caraccio,C. CBME theory to practice, 2010; 32: 638645
Competence

The array of abilities across multiple domains or aspects of physician


performance in a certain context.
Statements about competence require descriptive qualifiers to
define the relevant abilities, context, and stage of training.
Competence is multi-dimensional and dynamic.
It changes with time, experience, and setting.

Frank, J., Holmboe, E., Caraccio,C. CBME theory to practice, 2010; 32: 638645
Traditional vs Competency based:

TRADITIONAL MODEL Educational


objectives

Curriculum

ASSESSMENT
COMPETENCY BASED EDUCATIONAL MODEL

Health needs Competencies


CURRICULUM
Health systems outcome

ASSESSMENT
FRANK J., et al. Health professionals for new century: transformating education to strengthen health
systems in an interdependent world.Lancet 2010
Comparison of structure/Process vs
Competency based program
Key distinguishing feature of CBME

learners could potentially progress through the educational process


at different rates
the most capable and talented individuals should be able to make
career transitions earlier
others will require more time (up to a point) to attain a sufficient level
of knowledge, skills, and attitudes to enter unsupervised practice
RATIONALE FOR CBME Checklist

A focus on outcomes
OUTCOME

An emphasis on abilities
ABILITIES

A de-emphasis of time-based
FLEXI TIME training

SELF The promotion of learner-


centeredness

Frank, J., Holmboe, E., Caraccio,C. CBME theory to practice, 2010; 32: 638645
The transition to CBME
HIGH MEDIUM LOW - IMPACT + LOW MEDIUM HIGH

Knowledge
acquisition P Knowledge application

E
Setting removed Direct observation

Single subject
multiple subject measurement

S
measurement

Fixed length, Variable length, defined outcome

T
variable outcome

Norm reference Criterion reference

L
evaluation

Formative

E
Summative

CARACCIO, ET AL, 2010


EMPHASIS ON THE ABILITIES

Medical education tends to emphasize process issues (e.g.,


instructional methods) over outcomes (e.g., graduate performance
and satisfaction)
Medical education must prepare trainees for practice.

Frank, J., Holmboe, E., Caraccio,C. CBME theory to practice, 2010; 32: 638645
A de-emphasis of time-based training

Frank, J., Holmboe, E., Caraccio,C. CBME theory to practice, 2010; 32: 638645
The promotion of learner-centeredness
Abraham Flexner
Educational reform
1920

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2005 The quick brown fox jumps over the lazy dog. The
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Medical school to Residency- The Gaps

Wide variability in graduating students clinical skills measured as MS4s or


starting internship
Medical school to Residency- The Gaps
Wide variability in graduating students clinical skills
measured as MS4s or starting internship
- history taking
- examination
- counselling and informed consent
Calls for Reform in Medical Education

Standardize learning outcomes


Individualize learning while allowing flexibility and the
opportunity to progress as learners achieve competency
milestones!
Establish rigorous and progressively higher levels of
competency across the continuum of medical education!
Develop a coherent framework for the continuum of
medical education and establish effective mechanisms to
coordinate standards

Carnegie Foundation: Acad Med, Vol. 85 (2) 2010


Physician Skills for the Next Generation

Population health Leadership training


management/health Emotional intelligence
policy and regulation

Palliative
care/end-of-life
Systems theory and analysis
Resource management
medical economics Cross disciplinary training
multi-disciplinary teams

Less captain of the ship/ Understanding and respecting


more member/leader of the the skills of other practitioners
team
Giving formative feedback
Empathy/customer service
Time/conflict management Understanding cultural and economic diversity
American Hospital Association Task Force 2011
CBME- A new paradigm

You must specifically know the trainee has demonstrated expected


competence
Requires clear definition of expected outcomes or competencies :
milestones
Requires assessment and evaluation systems capable of
demonstrating that these things are done consistently and within the
clinical environment
(work-based assessment using EPAs)
Four components of CBME

1) identifying the outcomes


2) defining performance levels for each competency;
3) developing a framework for assessing competencies
4) continuous evaluation of the CBME program to see if it is indeed
producing the desired outcomesin this case, competent
physicians
FRAMEWORK: ACGME General Competencies
INTERPERSONAL SKILL &
COMMUNICATION
SKILLS
PATIENT CARE AND
PROCEDURAL SKILL

MEDICAL
KNOWLEDGE

STUDENT SYSTEM BASED


PRACTICE

PRACTICED BASED
LEARNING &
IMPROVEMENT PROFESSIONALISM
Domains of Competence (DoC) in the Physician
Competency Reference Set (PCRS)
1. Patient Care (PC)
2. Knowledge for Practice (KP)
3. Practice-based Learning and Improvement (PBLI)
4. Interpersonal and Communication Skills (ICS)
5. Professionalism (Prof)
6. Systems-based Practice (SBP)
7. Interprofessional Collaboration (IPC)
8. Personal and Professional Development (PPD)
CANMEDS Framework
Defining Performance Levels for the Competencies

Milestones are markers of achievement of levels of performance in a


developmental continuum.
Milestones is the definition of expected outcomes
By definition a milestone is a significant point in development
Milestones should enable the trainee, program and the certification board to
know an individuals trajectory of competency acquisition.
The milestones define the floor of competence but do not eliminate the need
for aspirational goals
Entrustable professional activities (EPAs)

The concept of entrustable means:


a practitioner has demonstrated the necessary knowledge, skills
and attittude to be trusted to independently perform this activity
without direct supervision
These activities are observable and measurable
EPAs require the integration of competenciesusually across
domainsand thus can be mapped to those competencies and
measured by their milestones that are critical to a supervisors
decision to entrust a learner

Englander, R.Developing a framework for competency. May 2015


Relationship between entrustable professional activities (EPAs),
domains of competence (DoC), competencies (C), and milestones (M).
WEST INDIAN MED J 2012: 61(7): 722

Subject: Saint Elizabeth Hospital with 422 beds

Objective: to evaluate whether a competency based curriculum im


Hospital fulfilled the requirements as defined by CanMEDS framewor

Methodology: Triangulation method


Methodology

4 visiting professors Medical educator


18 months
5 day visit 2 separate visits

Direct observation

Focused group interview


Medical residents, attending physicians

Data collected and analyzed by the 3 authors

Koeihers, JJ., Busari JO., Duits, AJ. A case study of the implementation of competency based Curriculum in a Caribbean teaching hospital,
West Indian Med J 2012; 61 (7): 727
Result:
1. Peer assessment of the department of internal medicine by visiting professors
assessors observed improvements in the educational process over time
the structure of the medical programme showed improvement over the study
period with visible and clearly defined clinical rotations at the end
content of the training programme required further development
Improvements on meeting for planned feedback

2. Assessment of the educational climate and quality of supervision by the visiting


medical educator
all competency areas are critically observed except health advocate
Most commended areas: medical expert and communication
Insufficient involvement for medical residents both on the wards and during
educational activities, as well as poor communication with patients, nurses,
trainees and residents.
Koeihers, JJ., Busari JO., Duits, AJ. A case study of the implementation of competency based Curriculum in a Caribbean teaching hospital,
West Indian Med J 2012; 61 (7): 727
Koeihers, JJ., Busari JO., Duits, AJ. A case study of the implementation of competency based Curriculum in a Caribbean teaching hospital,
West Indian Med J 2012; 61 (7): 727
Koeihers, JJ., Busari JO., Duits, AJ. A case study of the implementation of competency based Curriculum in a Caribbean teaching hospital,
West Indian Med J 2012; 61 (7): 727
Conclusion

The implemented assessment programme provided necessary information for


effective evaluation of the competency-based curriculum.
They were able to identify new and feasible methods for improving the
curriculum in our educational setting.

Koeihers, JJ., Busari JO., Duits, AJ. A case study of the implementation of competency based Curriculum in a Caribbean teaching hospital,
West Indian Med J 2012; 61 (7): 727
Objective: To compare knowledge acquisition, clinical performance and
perceived preparedness for practice of students from a competency-based
active learning (CBAL) curriculum and a prior active learning (AL) curriculum.

Methods: two cohorts: AL curriculum (n = 453) and CBAL curriculum (n = 372).


Differences in knowledge acquisition were determined comparing the number
of times CBAL and AL cohorts scored significantly higher or lower on progress
tests. Clinical performance was operationalized as students mean clerkship
grade. Perceived preparedness for practice was assessed using a survey.

Participants :Undergraduate medical education in The Netherlands lasts 6


years. We included students who graduated within 7 years from the start of the
last 2 cohorts of the AL curriculum (2001/2002 and 2002/2003; N = 453) and the
first 2 cohorts of the CBAL curriculum (2003/2004 and 2004/2005; N = 372).
Results:
Knowledge acquisition
The AL cohorts scored significantly higher
10 (2001 2002; ES 0.300.57)
14 progress tests (20022003; ES 0.270.66)
significantly lower on 1 progress test (20012002; ES 0.31)
The CBAL cohorts scored significantly higher
2 progress tests (20032004; ES 0.30 and 0.34)
significantly lower on 2 (20032004; ES 0.24 and 0.27)
4 progress tests (20042005; ES 0.230.44) than cohorts from the other
two medical schools (Figure 1).
None of the 4 cohorts scored significantly different on the last three
tests of the final year.
STEPS IN PLANNING CBME

1. Identify the abilities needed of graduates.


2. Explicitly define the required competencies and their components.
3. Define milestones along a development path for the competencies.
4. Select educational activities, experiences, and instructional methods.
5. Select assessment tools to measure progress along the milestones.
6. Design an outcomes evaluation of the program.
IMPLICATIONS OF CBME APPROACH

Among the benefits promised by the adoption of CBME are


1. A new paradigm of competence
2. A renewed commitment to outcome
3. A new focus for assessment on developmental milestones.
4. A mechanism to promote a true continuum of medical education
5. A method to promote learner-centered curricula.
6. A way to de-emphasize time-based credentialing in mediicine.
7. Potential for portability of training
IMPLICATIONS OF CBME APPROACH

Among the potential perils and challenges of CBME are


1. The threat of reductionism.
2. Promoting the lowest common denominator.
3. Logistical chaos.
4. Loss of authenticity
5. The tyranny of utility.
6. The need for new educational technologies.
7. Inertia and lack of resources.
SUMMARY
The greatest obstacle to discovery is not ignorance, it is the illusion of
knowledge

- Daniel J Boorstin
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P E S T L E

Frank, J., Holmboe, E., Caraccio,C. CBME theory to practice, 2010; 32: 638645
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