Effects of implementing time-variable postgraduate training programmes on the organization of teaching hospital departments

Competency-Based Time-Variable Anesthesiology Residency Training: Identification of Problems and Solutions

BACKGROUND

Global medical education is gradually moving toward more comprehensive implementations of a competency-based education (CBE) model. Elimination of standard time-based training and adoption of time-variable training (competency-based time-variable training [CB-TVT]) is one of the final stages of implementation of CBE. While CB-TVT has been implemented in some programs outside the United States, residency programs in the United States are still exploring this approach to training. The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) are encouraging member boards and residency review committees to consider innovative ways programs could implement CB-TVT. The goals of this study were to (1) identify potential problems with the implementation of CB-TVT in anesthesiology residency training, (2) rank the importance of the problems and the perceived difficulty of solving them, and (3) develop proposed solutions to the identified problems.

METHODS

Study participants were recruited from key stakeholder groups in anesthesiology education, including current or former program directors, department chairs, residents, fellows, American Board of Anesthesiology (ABA) board members, ACGME residency review committee members or ACGME leaders, designated institutional officials, residency program coordinators, clinical operations directors, and leaders of large anesthesiology community practice groups. This study was conducted in 2 phases. In phase 1, survey questionnaires were iteratively distributed to participants to identify problems with the implementation of CB-TVT. Participants were also asked to rank the perceived importance and difficulty of each problem and to identify relevant stakeholder groups that would be responsible for solving each problem. In phase 2, surveys focused on identifying potential solutions for problems identified in phase 1.

RESULTS

A total of 36 stakeholders identified 39 potential problems, grouped into 7 major categories, with the implementation of CB-TVT in anesthesiology residency training. Of the 39 problems, 19 (48.7%) were marked as important or very important on a 5-point scale and 12 of 19 (63.2%) of the important problems were marked as difficult or very difficult to solve on a 5-point scale. Stakeholders proposed 165 total solutions to the identified problems.

CONCLUSIONS

CB-TVT is a promising educational model for anesthesiology residency, which potentially results in learner flexibility, individualization of curricula, and utilization of competencies to determine learner advancement. Because of the potential problems with the implementation of CB-TVT, it is important for future pilot implementations of CB-TVT to document realized problems, efficacy of solutions, and effects on educational outcomes to justify the burden of implementing CB-TVT.

Lessons learned spanning 17 years of experience with three consecutive nationwide competency based medical education training plans

Introduction

Curricula for postgraduate medical education have transformed since the introduction of competency based medical education (CBME). Postgraduate training plans offer broader training with different competencies and an outcome-based approach, in addition to the medical technical aspects of training. However, CBME also has its challenges. Over the past years, critical views have been shared on the potential drawbacks of CBME, such as assessment burden and conflicts with practicality in the workplace. Recent studies identified a need for a better understanding of how the evolving concept of CBME has been translated to curriculum design and implemented in the practice of postgraduate training. The aim of this study was to describe the development of CBME translations to curriculum design, based on three consecutive postgraduate training programs spanning 17 years.

Method

We performed a document analysis of three consecutive Dutch gynecology and obstetrics training plans that were implemented in 2005, 2013, and 2021. We used template analysis to identify changes over time.

Results

Over time, CBME-based curriculum design changed in several domains. Assessment changed from a model with a focus on summative decision to one with an emphasis on formative, low-stakes assessments aimed at supporting learning. The training plans evolved in parallel to evolving educational insights, e.g., by placing increasing emphasis on personal development. The curricula focused on a competency-based concept by introducing training modules and personalized authorization based on feedback rather than on a set duration of internships. There was increasing freedom in personalized training trajectories in the training plans, together with increasing trust towards the resident.

Conclusion

The way CBME was translated into training plans has evolved in the course of 17 years of experience with CMBE-based education. The main areas of change were the structure of the training plans, which became increasingly open, the degree to which learning outcomes were mandatory or not, and the way these outcomes were assessed.

Capturing outcomes of competency-based medical education: The call and the challenge

There is an urgent need to capture the outcomes of the ongoing global implementation of competency-based medical education (CBME). However, the measurement of downstream outcomes following educational innovations, such as CBME is fraught with challenges stemming from the complexities of medical training, the breadth and variability of inputs, and the difficulties attributing outcomes to specific educational elements. In this article, we present a logic model for CBME to conceptualize an impact pathway relating to CBME and facilitate outcomes evaluation. We further identify six strategies to mitigate the challenges of outcomes measurement: (1) clearly identify the outcome of interest, (2) distinguish between outputs and outcomes, (3) carefully consider attribution versus contribution, (4) connect outcomes to the fidelity and integrity of implementation, (5) pay attention to unanticipated outcomes, and (6) embrace methodological pluralism. Embracing these challenges, we argue that careful and thoughtful evaluation strategies will move us forward in answering the all-important question: Are the desired outcomes of CBME being achieved?

The Implementation of Entrustable Professional Activities in Postgraduate Medical Education in the Netherlands: Rationale, Process, and Current Status

Postgraduate medical education in the Netherlands has adopted competency-based education since the turn of the century. In 2006, the CanMEDS competency framework was introduced. A 2013 government plan to reduce the length and budgets of training programs led the Dutch Association of Medical Specialists (DAMS) to respond with a proposal to create more flexibility and individualization rather than a blunt cut in the length across all training programs. DAMS launched a government-funded, nation-wide, 4-year project (2014-2018) to blueprint the reform of postgraduate medical education in this direction. To achieve competency-based individualization, the fixed duration of postgraduate programs was abandoned, and entrustable professional activities (EPAs) were introduced in all specialty programs. Implementation of this new generation of programs took place in 2017-2019 in all disciplines. The project focused on EPA-based individualization of all programs, while addressing issues of the continuity of patient care in time-variable programs and the legal and regulatory consequences of individualization. About 30 specialty programs were revised at national, regional, local, and individual levels to incorporate EPAs; portfolio systems were adapted, clinical competency committees were installed for all programs, and procedures for summative entrustment decision making were elaborated. This paper reports on the rationale and the process that led to a more time-variable postgraduate education landscape, and, on average, a shortening of training length by 3 months.

Managing tensions in assessment: moving beyond either-or thinking

CONTEXT

In health professions education, assessment systems are bound to be rife with tensions as they must fulfil formative and summative assessment purposes, be efficient and effective, and meet the needs of learners and education institutes, as well as those of patients and health care organisations. The way we respond to these tensions determines the fate of assessment practices and reform. In this study, we argue that traditional 'fix-the-problem' approaches (i.e. either-or solutions) are generally inadequate and that we need alternative strategies to help us further understand, accept and actually engage with the multiple recurring tensions in assessment programmes.

METHODS

Drawing from research in organisation science and health care, we outline how the Polarity Thinking™ model and its 'both-and' approach offer ways to systematically leverage assessment tensions as opportunities to drive improvement, rather than as intractable problems. In reviewing the assessment literature, we highlight and discuss exemplars of specific assessment polarities and tensions in educational settings. Using key concepts and principles of the Polarity Thinking™ model, and two examples of common tensions in assessment design, we describe how the model can be applied in a stepwise approach to the management of key polarities in assessment.

DISCUSSION

Assessment polarities and tensions are likely to surface with the continued rise of complexity and change in education and health care organisations. With increasing pressures of accountability in times of stretched resources, assessment tensions and dilemmas will become more pronounced. We propose to add to our repertoire of strategies for managing key dilemmas in education and assessment design through the adoption of the polarity framework. Its 'both-and' approach may advance our efforts to transform assessment systems to meet complex 21st century education, health and health care needs.