Changing the culture of medical training: An important step toward the implementation of competency-based medical education

Developing a National Competency-Based Diabetes Curriculum in Undergraduate Medical Education: A Delphi Study

OBJECTIVES

In recent years there has been an increased emphasis on competency-based medical education (CBME) in Canada and internationally, as can be seen with the implementation of competency-based curriculums for postgraduate medical education (PGME) through the Royal College of Physicians and Surgeons of Canada. Currently, no Canada-wide consensus exists on educational competencies relating to diabetes in undergraduate medical education (UGME). Our aim in this study was to develop a list of competencies and objectives for UGME in diabetes using a modified Delphi method.

METHODS

Representatives involved in the development of the diabetes curriculum at all 17 medical schools across Canada were contacted. A draft list of competencies and objectives was developed by the research team using the existing curriculums at 9 Canadian medical schools and was organized using the CanMEDS framework. A Delphi method was used, with 2 iterations in order to reach consensus.

RESULTS

Twelve of 17 medical schools agreed to participate. Of the 12 surveys sent in the first round, 8 responses were received (response rate 66.7%). The revised version was then resent to the 8 respondents and 7 responses were received (response rate 87.5%). A list of 9 competencies and 62 objectives was finalized.

CONCLUSIONS

A competency-based consensus curriculum for diabetes education for undergraduate medical students was developed using a modified Delphi method. The final consensus syllabus will be disseminated across the country. This curriculum serves as a step in the transition to competency-based UGME and in ensuring that future medical school graduates are proficient in diabetes care.

Whether introduction of competency-based medical education should be advocated in India?

BACKGROUND:

The healthcare needs of the general population are on the rise and to meet these demands, the healthcare professionals, especially doctors have to acquire a large number of skills. In the Indian settings, as of now, conventional system of education is being followed in medical colleges and this is despite the fact that it has many flaws associated with it.

AIMS AND OBJECTIVES:

The objective of the article is to explore the utility and the need of Competency Based Medical Education (CBME) in Indian settings.

MATERIALS AND METHODS:

It is a brief review of pertaining to the transition of delivery of medical education in India and is well-supported by the studies from different nations.

RESULTS:

CBME is a thoughtful approach to develop physicians in their future practice and encourages better accountability and flexibility. However, if so many things are good with CBME, then the question arises why it has not been implemented yet across all the medical colleges in India? This is because of the various challenges which have been identified in the planning and implementation phase of the program.

CONCLUSION:

In conclusion, CBME remains the ultimate solution for the problems persisting in the conventional system of medical education. However, a systemic plan and better involvement of the stakeholders in the preparedness phase will significantly enhance the chances of the success of the program.

Who owns responsibility? An administrator's take on implementing time-variable medical training in teaching hospitals

Introduction: Developments in outcome-based medical education led to the introduction of time-variable medical training (TVMT). Although this idea of training may be a consequence of competency-based training that calls for individualized learning, its implementation has posed significant challenges. As a new paradigm it is likely to have repercussions on the organization of teaching hospitals. The purpose of this study is therefore to explore how hospital administrators cope with this implementation process. Methods: We conducted an exploratory qualitative study for which we interviewed administrators of hospitals who were actively implementing TVMT in their postgraduate programs. Results: Several problems of implementation were identified: existing governance structures proved unfit to cope with the financial and organizational implications of TVMT. Administrators responded to these problems by delegating responsibilities to departments, reallocating tasks, learning from other hospitals and scaling up their teaching facilities. Conclusions: Hospital administrators perceived the implementation of TVMT as challenging. TVMT affects the existing equilibrium between education and clinical service. Administrators' initial attempts to regain control, using steering strategies that were based on known concepts and general outcomes, including cutting departmental budgets did not work, nor did their subsequent wait-and-see approach of leaving the implementation to the individual departments.

Competency-Based Medical Education implementation: Are we transforming the culture of assessment?

Purpose: Adopting CBME is challenging in medicine. It mandates a change in processes and approach, ultimately a change in institutional culture with stakeholders ideally embracing and valuing the new processes. Adopting the transformational change model, this study describes the shift in assessment culture by Academic Advisors (AAs) and preceptors over three years of CBME implementation in one Department of Family Medicine. Methods: A qualitative grounded theory method was used for this two-part study. Interviews were conducted with 12 AAs in 2013 and nine AAs in 2016 using similar interview questions. Data were analyzed through a constant comparative method. Results: Three overarching themes emerged from the data: (1) specific identified shifts in assessment culture, (2) factors supporting the shifts in culture, and (3) outcomes related to the culture shift. Conclusions: In both parts of the study, participants noted that assessment took more time and effort. In Part 2, however, the effort was mitigated by a sense of value for all stakeholders. With support from the mandate of regulatory bodies, local leadership, department, faculty development and an electronic platform, a cultural transformation occurred in assessment that enhanced learning and teaching, use of embedded standards for performance decisions, and tracking and documentation performance.

Intrinsic roles in the crosshair - strategic analysis of multi-site role implementation with an adapted matrix map approach

BACKGROUND

The implementation of competency-based intrinsic roles in undergraduate medical education remains a challenge. Faculties in transition need to be provided with generalizable curricular data in order to facilitate orientation on curricular roles' representation and to decide on steps of curriculum development. Explicit and implicit representation of objectives and multi-site agreement can be viewed as status indicators for the adoption of roles. Our aim was to develop a pragmatic cross-locational approach to capture roles' developmental status in an overview and prioritize strategic recommendations.

METHODS

Based on the mapping data from six German medical faculties, the relationship between explicit and implicit curricular representation of role' objectives (weighting) and extent of programs' consent (agreement) was calculated. Data was visualized in a role-specific Matrix Map to analyse roles' implicit-explicit relation and risk-value potential. The matrix was combined with Roger's stages of innovation diffusion for differentiated interpretation of the developmental role status.

RESULTS

Entangling multi-site agreement and curricular weighting, the 4-Field-Matrix allows to assess objectives based on their current localization in a quadrant: "Disregard" (lower left) and "Progress" quadrant (upper left) reveal the diffusion period; "Potential" (lower right) and "Emphasis" quadrant (upper right) indicate the adoption period. The role patterns differ in curricular representation, progression and clarity: (1) Scholar: explicit/implicit - scattered across the matrix; most explicit objectives in "Progress". (2) Health Advocate: explicit - primarily in "Emphasis"; only role in which the explicit representation significantly exceeds the implicit. (3) Collaborator: explicit - mainly "Potential"; implicit - "Progress" or "Emphasis". (4) Professional: explicit - primarily "Potential" but also "Emphasis"; implicit - "Progress" and "Emphasis"; appears better adopted but scattered in weighting; high hidden curricula. (5) Manager: explicit and implicit - exclusively in "Potential", without signs of development. Role patterns correspond to evidences from literature. Exemplified with roles, quadrant-specific strategies and measures are suggested. Framework reviewers may gain information for discussion of critical content.

CONCLUSION

The Matrix Map enables to catch intuitively the status of intrinsic roles' profiles regarding role pattern, implicit-explicit relation and programs agreement. Thus, interpretation and informed discussions are fostered. Further target-oriented analyses and strategic developments can be conducted to enhance transparency and resource-efficiency.

Faculty development in the age of competency-based medical education: A needs assessment of Canadian emergency medicine faculty and senior trainees

OBJECTIVES

The Royal College of Physicians and Surgeons of Canada (RCPSC) emergency medicine (EM) programs transitioned to the Competence by Design training framework in July 2018. Prior to this transition, a nation-wide survey was conducted to gain a better understanding of EM faculty and senior resident attitudes towards the implementation of this new program of assessment.

METHODS

A multi-site, cross-sectional needs assessment survey was conducted. We aimed to document perceptions about competency-based medical education, attitudes towards implementation, perceived/prompted/unperceived faculty development needs. EM faculty and senior residents were nominated by program directors across RCPSC EM programs. Simple descriptive statistics were used to analyse the data.

RESULTS

Between February and April 2018, 47 participants completed the survey (58.8% response rate). Most respondents (89.4%) thought learners should receive feedback during every shift; 55.3% felt that they provided adequate feedback. Many respondents (78.7%) felt that the ED would allow for direct observation, and most (91.5%) participants were confident that they could incorporate workplace-based assessments (WBAs). Although a fair number of respondents (44.7%) felt that Competence by Design would not impact patient care, some (17.0%) were worried that it may negatively impact it. Perceived faculty development priorities included feedback delivery, completing WBAs, and resident promotion decisions.

CONCLUSIONS

RCPSC EM faculty have positive attitudes towards competency-based medical education-relevant concepts such as feedback and opportunities for direct observation via WBAs. Perceived threats to Competence by Design implementation included concerns that patient care and trainee education might be negatively impacted. Faculty development should concentrate on further developing supervisors' teaching skills, focusing on feedback using WBAs.

Qualitative study to identify the perception and challenges faced by the faculty of community medicine in the implementation of competency-based medical education for postgraduate students

Objectives

To identify perception about the key aspects of competency-based medical education (CBME) among community medicine faculty members and to ascertain the various challenges faced by them during its implementation.

Methods

A descriptive qualitative study of 2 months’ duration was conducted among the faculty members of the community medicine department. Non-probability purposive sampling was employed in the study. Free listing was done initially to elicit the views of faculty members to meet the intended objectives. Visual Anthropac software was used to identify the salient variables using Smith’s Salience Score, and then pile sorting was done to identify the association between the salient variables.

Results

Three faculty members participated in the free listing and pile sorting. A total of 20 responses were obtained pertaining to the key aspects of CBME, of which 12 were identified as the salient variables depending on the cut-off value of 0.125 (Smith’s Salience Score) and subjected to pile sorting. Similarly, eight challenges were identified in the implementation of the programme during the free listing, and all were included in the second stage of pile sorting. Cognitive maps were drawn to understand the relationship between the key aspects of CBME and involved challenges separately.

Conclusion

On employing the free listing and pile sorting methods, formulation of entrustable professional activities and their assessment using appropriate tools were the identified crucial areas in CBME, while the lack of sensitisation of stakeholders and inadequate planning were identified as the predominant challenges in the implementation of CBME.

Faculty Development Revisited: A Systems-Based View of Stakeholder Development to Meet the Demands of Entrustable Professional Activity Implementation

In 2015, the Association of American Medical Colleges implemented an interinstitutional pilot of 13 core entrustable professional activities (EPAs) for entering residency, activities that entering residents should be expected to perform with indirect supervision. The pilot included a concept group on faculty development; this group previously offered a shared mental model focused on the development of faculty who devote their efforts to clinical teaching and assessment for learning and entrustment decision making. In this article, the authors draw from the literature of competency-based education to propose what is needed in overall approaches to faculty development to prepare institutions for undergraduate EPA implementation.Taking a systems-based view that defines the necessary tasks of EPA implementation, the authors move beyond the variably used term "faculty" and enumerate a comprehensive list of institutional stakeholders who can meaningfully support and/or engage in the relationships and organizational processes required for EPA learning and assessment. They consider each group's responsibilities and development needs according to five domains delineated by Steinert: teaching improvement, leadership and management, research-building capacity, academic career building, and organizational change.The authors argue that the EPA framework addresses barriers posed with the use of a competency-based framework. By facilitating the communication required for organizational change, enabling valid assessment with comprehensive yet feasible levels of faculty development, and incorporating all relevant data on student professional behavior into summative assessment decisions, EPAs may offer a clearer path toward the goal of competency-based education.

Optimizing engagement of undergraduate students in medical education research: The eMERG training network

Background

The practice of evidence-based medicine and critical appraisal are essential for the modern doctor. Early engagement of medical students in research methodology is considered as a rising need for most medical school curricula; however, few peer-reviewed initiatives have been reported so far. We developed a Medical Education Research Group (eMERG) as part of a novel undergraduate surgical masterclass, which aimed to train undergraduate students on basic research methodology, as well as to motivate them to pursue a clinical and academic career in surgical specialties.

Methods: eMERG consists of an international structured network of senior academics, consultant-level clinicians, senior and junior trainees who support undergraduate trainees. Students are selected from a competitive pool of applicants. Several small prospective studies in skills-based education, as well as systematic reviews on similar topics, have run under the umbrella of this framework, in the form of scholarship awards. Structured feedback questionnaires were distributed to evaluate the experience of the first three years.

Results

12 students have participated in this pilot initiative. 11 manuscripts have been submitted for publication and 8 were accepted following peer-review in MEDLINE-indexed journals. Delegates perceived this experience as an excellent training opportunity which improved their research productivity. Delegates also stated engagement in research developed interest in the relevant surgical speciality, impacting their career aspirations.

Conclusions

eMERG is one of the first reported European educational research networks for undergraduates. Research outcomes and students' perceptions conclude that eMERG enhances engagement with research methodology and motivation towards a career in surgery.

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eMERG is a pilot international research training network where medical students receive support to conduct research in Medical Education.

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eMERG structure can serve as a novel model to convey research experience from one generation to another, and in the same time, motivate and aspire students to develop leadership skills.

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eMERG was developed in a financial crisis environment with promising research outputs and positive students' feedback.

Perceptions of busyness in the emergency department: an opportunity to address a training gap through competency based education

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Implementing competency-based medical education: What changes in curricular structure and processes are needed?

Medical educators must prepare for a number of challenges when they decide to implement a competency-based curriculum. Many of these challenges will pertain to three key aspects of implementation: organizing the structural changes that will be necessary to deliver new curricula and methods of assessment; modifying the processes of teaching and evaluation; and helping to change the culture of education so that the CBME paradigm gains acceptance. This paper focuses on nine key considerations that will support positive change in first two of these areas. Key considerations include: ensuring that educational continuity exists amongst all levels of medical education, altering how time is used in medical education, involving CBME in human health resources planning, ensuring that competent doctors work in competent health care systems, ensuring that information technology supports CBME, ensuring that faculty development is supported, ensuring that the rights and responsibilities of the learner are appropriately balanced in the workplace, preparing for the costs of change, and having appropriate leadership in order to achieve success in implementation.

Evolving concepts of assessment in a competency-based world

Competency-based medical education (CBME) is an approach to the design of educational systems or curricula that focuses on graduate abilities or competencies. It has been adopted in many jurisdictions, and in recent years an explosion of publications has examined its implementation and provided a critique of the approach. Assessment in a CBME context is often based on observations or judgments about an individual's level of expertise; it emphasizes frequent, direct observation of performance along with constructive and timely feedback to ensure that learners, including clinicians, have the expertise they need to perform entrusted tasks. This paper explores recent developments since the publication in 2010 of Holmboe and colleagues' description of CBME assessment. Seven themes regarding assessment that arose at the second invitational summit on CBME, held in 2013, are described: competency frameworks, the reconceptualization of validity, qualitative methods, milestones, feedback, assessment processes, and assessment across the medical education continuum. Medical educators interested in CBME, or assessment more generally, should consider the implications for their practice of the review of these emerging concepts.

Overarching challenges to the implementation of competency-based medical education

Medical education is under increasing pressure to more effectively prepare physicians to meet the needs of patients and populations. With its emphasis on individual, programmatic, and institutional outcomes, competency-based medical education (CBME) has the potential to realign medical education with this societal expectation. Implementing CBME, however, comes with significant challenges. This manuscript describes four overarching challenges that must be confronted by medical educators worldwide in the implementation of CBME: (1) the need to align all regulatory stakeholders in order to facilitate the optimization of training programs and learning environments so that they support competency-based progression; (2) the purposeful integration of efforts to redesign both medical education and the delivery of clinical care; (3) the need to establish expected outcomes for individuals, programs, training institutions, and health care systems so that performance can be measured; and (4) the need to establish a culture of mutual accountability for the achievement of these defined outcomes. In overcoming these challenges, medical educators, leaders, and policy-makers will need to seek collaborative approaches to common problems and to learn from innovators who have already successfully made the transition to CBME.

Implementing competency-based medical education: Moving forward

For more than 60 years, competency-based education has been proposed as an approach to education in many disciplines. In medical education, interest in CBME has grown dramatically in the last decade. This editorial introduces a series of papers that resulted from summits held in 2013 and 2016 by the International CBME Collaborators, a scholarly network whose members are interested in developing competency-based approaches to preparing the next generation of health professionals. An overview of the papers is given, as well as a summary of landmarks in the conceptual evolution and implementation of CBME. This series follows on a first collection of papers published by the International CBME Collaborators in Medical Teacher in 2010.