It's a Marathon, Not a Sprint: Rapid Evaluation of Competency-Based Medical Education Program Implementation

Unveiling the paradoxes of implementing post graduate competency based medical education programs

PURPOSE

Competency-based medical education (CBME) has gained prominence as an innovative model for post-graduate medical education, yet its implementation poses significant challenges, especially with regard to its sustainability. Drawing on paradox theory, we suggest that revealing the paradoxes underlying these challenges may contribute to our understanding of post graduate competency-based medical education (PGCBME) implementation processes and serve as a first-step in enhancing better implementation. Thus, the purpose of the current study is to identify the paradoxes associated with PGCBME implementation.

METHOD

A qualitative study was conducted, as part of a larger action research, using in-depth semi-structured interviews with fellows and educators in eight Neonatal wards.

RESULTS

Analysis revealed that the PGCBME program examined in this study involves three different levels of standardization, each serving as one side of paradoxical tensions; (1) a paradox between the need for standardized assessment tools and for free-flow flexible assessment tools, (2) a paradox between the need for a standardized implementation process across all wards and the need for unique implementation protocols in each ward; and 3) a paradox between the need for a standardized meaning of competency proficiency and the need for flexible and personal competency achievement indicators.

CONCLUSIONS

Implementing PGCBME programs involves many challenges, some of which are paradoxical, i.e. two contradictory challenges in which solving one challenge exacerbates another. Revealing these paradoxes is important in navigating them successfully.

Was it all worth it? A graduating resident perspective on CBME

BACKGROUND

Our institution simultaneously transitioned all postgraduate specialty training programs to competency-based medical education (CBME) curricula. We explored experiences of CBME-trained residents graduating from five-year programs to inform the continued evolution of CBME in Canada.

METHODS

We utilized qualitative description to explore residents' experiences and inform continued CBME improvement. Data were collected from fifteen residents from various specialties through focus groups, interviews, and written responses. The data were analyzed inductively, using conventional content analysis.

RESULTS

We identified five overarching themes. Three themes provided insight into residents' experiences with CBME, describing discrepancies between the intentions of CBME and how it was enacted, challenges with implementation, and variation in residents' experiences. Two themes - adaptations and recommendations - could inform meaningful refinements for CBME going forward.

CONCLUSIONS

Residents graduating from CBME training programs offered a balanced perspective, including criticism and recognition of the potential value of CBME when implemented as intended. Their experiences provide a better understanding of residents' needs within CBME curricula, including greater balance and flexibility within programs of assessment and curricula. Many challenges that residents faced with CBME could be alleviated by greater accountability at program, institutional, and national levels. We conclude with actionable recommendations for addressing residents' needs in CBME.

Current use of simulation for EPA assessment in emergency medicine

OBJECTIVE

Approximately five years ago, the Royal College emergency medicine programs in Canada implemented a competency-based paradigm and introduced the use of Entrustable Professional Activities (EPAs) for assessment of units of professional activity to assess trainees. Many competency-based medical education (CBME) based curricula, involve assessing for entrustment through observations of EPAs. While EPAs are frequently assessed in clinical settings, simulation is also used. This study aimed to characterize the use of simulation for EPA assessment.

METHODS

A study interview guide was jointly developed by all study authors and followed best practices for survey development. A national interview was conducted with program directors or assistant program directors across all the Royal College emergency medicine programs across Canada. Interviews were conducted over Microsoft Teams, interviews were recorded and transcribed, using Microsoft Teams transcribing service. Sample transcripts were analyzed for theme development. Themes were then reviewed by co-authors to ensure they were representative of the participants' views.

RESULTS

A 64.7% response rate was achieved. Simulation has been widely adopted by EM training programs. All interviewees demonstrated support for the use of simulation for EPA assessment for many reasons, however, PDs acknowledged limitations and thematic analysis revealed certain themes and tensions for using simulation for EPA assessment. Thematic analysis revealed six major themes: widespread support for the use of simulation for EPA assessment, concerns regarding the potential for EPA assessment to become a "tick- box" exercise, logistical barriers limiting the use of simulation for EPA assessment, varied perceptions about the authenticity of using simulation for EPA assessment, the potential for simulation for EPA assessment to compromise learner psychological safety, and suggestions for the optimization of use of simulation for EPA assessment.

CONCLUSIONS

Our findings offer insight for other programs and specialties on how simulation for EPA assessment can best be utilized. Programs should use these findings when considering using simulation for EPA assessment.

Evaluating Competence by Design as a Large System Change Initiative: Readiness, Fidelity, and Outcomes

Program evaluation is an essential, but often neglected, activity in any transformational educational change. Competence by Design was a large-scale change initiative to implement a competency-based time-variable educational system in Canadian postgraduate medical education. A program evaluation strategy was an integral part of the build and implementation plan for CBD from the beginning, providing insights into implementation progress, challenges, unexpected outcomes, and impact. The Competence by Design program evaluation strategy was built upon a logic model and three pillars of evaluation: readiness to implement, fidelity and integrity of implementation, and outcomes of implementation. The program evaluation strategy harvested from both internally driven studies and those performed by partners and invested others. A dashboard for the program evaluation strategy was created to transparently display a real-time view of Competence by Design implementation and facilitate continuous adaptation and improvement. The findings of the program evaluation for Competence by Design drove changes to all aspects of the Competence by Design implementation, aided engagement of partners, supported change management, and deepened our understanding of the journey required for transformational educational change in a complex national postgraduate medical education system. The program evaluation strategy for Competence by Design provides a framework for program evaluation for any large-scale change in health professions education.

Using a rapid-cycle approach to evaluate implementation of competency-based medical education in ophthalmology

OBJECTIVE

As competency-based medical education is being implemented across Canada, there is an increasing need to evaluate the progress to date, including identification of strengths and weaknesses, to inform program development. Ophthalmology is preparing for a national launch in coming years. The purpose of this study was to describe key stakeholders' lived experiences in the competency-based medical education foundation-of-discipline stage in one ophthalmology department.

DESIGN

Using a case-study approach, a qualitative rapid-cycle evaluation was conducted during the 2018-2019 academic year.

PARTICIPANTS

Residents, faculty, academic advisors, competence committee members, the program director, the program administrator, and the educational consultant were invited to participate in the program evaluation.

METHODS

The rapid-cycle evaluation consisted of 2 evaluation cycles, with the first round of interviews and focus groups occurring in October 2018 and the second round in March 2019. Recommendations were implemented in November 2019 and June 2019. All data were analyzed thematically using NVivo.

RESULTS

Three main themes emerged across all data sets: developing a shared understanding (e.g., role expectations and changes to assessment), refining assessment processes and tools (e.g., the need for streamlining and clarification), and feedback (e.g., perceived benefits and value of narrative comments).

CONCLUSIONS

Exploring lived experiences in this study resulted in positive and immediate improvements to the residency program. The recommendations and approach will be useful to other Canadian departments and institutions as they prepare for Competence by Design.

Preliminary Development of a Program ABSITE Dashboard (PAD) to Guide Curriculum Innovation

PURPOSE

Medical Knowledge for general surgery residents' is assessed by the American Board of Surgery In- Training Examination (ABSITE). ASBITE score reports contain many metrics residency directors can utilize to assess resident progress and perform program evaluation. The purpose of this study was to develop a framework to evaluate program effectiveness in teaching specific subtest and subtopic areas of the ABSITE, using ABSITE score reports as an indicator. The aim is to demonstrate the identification of topic areas of weakness in program-wide performance on the ABSITE to guide proposed modification of the general surgery residency program curriculum, and to initiate development of a data visualizing dashboard to communicate these metrics.

METHODS

A single institution retrospective study was performed utilizing ABSITE score reports from general surgery residents at a large academic training program from 2017 to 2020. ABSITE performance metrics from 320 unique records were entered into a database; statistical analysis for linear trends and variance were conducted for standard scores, subtest standard scores, and incorrect subtest topics. Deviation from national average scores were calculated by subtracting the national average score from each subtest score for each trainee. Data were displayed as medians or proportions and are displayed to optimize visualization as a proof-of-concept for the development of a program dashboard.

RESULTS

Trends and variance in general surgery program and cohort performance on various elements of the ABSITE were visualized using figures and tables that represent a prototype for a program dashboard. Figure A1 demonstrates one example, in which a heatmap displays the median deviation from national average scores for each subtest by program year. Boxplots show the distribution of the deviation from national average, range for national average scores, and the recorded scores for each subtest by program year. Trends in median deviation from the national average scores are displayed for each program year paneled by subtest or for each exam year paneled by cohort. Median change in overall test scores from one program year to another in a cohort is visualized as a table. Bar graphs show the most often missed topics across all program years and heatmaps were generated showing the proportion of times each topic was missed for each subtest and exam year.

CONCLUSIONS

We demonstrate use of ABSITE reports to identify specific thematic areas of opportunities for curriculum modification and innovation as an element of program evaluation. In this study we demonstrate, through data analysis and visualization, feasibility for the creation of a Program ABSITE Dashboard (PAD) that enhances the use of ABSITE reports for formative program evaluation and can guide modifications to surgery program curriculum and educational practices.

Competency-based medical education: The spark to ignite healthcare's escape fire

High-value care is what patients deserve and what healthcare professionals should deliver. However, it is not what happens much of the time. Quality improvement master Dr. Don Berwick argued more than two decades ago that American healthcare needs an escape fire, which is a new way of seeing and acting in a crisis situation. While coined in the U.S. context, the analogy applies in other Western healthcare contexts as well. Therefore, in this paper, the authors revisit Berwick's analogy, arguing that medical education can, and should, provide the spark for such an escape fire across the globe. They assert that medical education can achieve this by fully embracing competency-based medical education (CBME) as a way to place medicine's focus on the patient. CBME targets training outcomes that prepare graduates to optimize patient care. The authors use the escape fire analogy to argue that medical educators must drop long-held approaches and tools; treat CBME implementation as an adaptive challenge rather than a technical fix; demand genuine, rich discussions and engagement about the path forward; and, above all, center the patient in all they do.

Lessons learned and new strategies for success: Evaluating the Implementation of Competency-Based Medical Education in Queen's Pediatrics

Objectives

In 2017, Queen's University launched Competency-Based Medical Education (CBME) across 29 programs simultaneously. Two years post-implementation, we asked key stakeholders (faculty, residents, and program leaders) within the Pediatrics program for their perspectives on and experiences with CBME so far.

Methods

Program leadership explicitly described the intended outcomes of implementing CBME. Focus groups and interviews were conducted with all stakeholders to describe the enacted implementation. The intended versus enacted implementations were compared to provide insight into needed adaptations for program improvement.

Results

Overall, stakeholders saw value in the concept of CBME. Residents felt they received more specific feedback and monthly Competence Committee (CC) meetings and Academic Advisors were helpful. Conversely, all stakeholders noted the increased expectations had led to a feeling of assessment fatigue. Faculty noted that direct observation and not knowing a resident's previous performance information was challenging. Residents wanted to see faculty initiate assessments and improved transparency around progress and promotion decisions.

Discussion

The results provided insight into how well the intended outcomes had been achieved as well as areas for improvement. Proposed adaptations included a need for increased direct observation and exploration of faculty accessing residents' previous performance information. Education was provided on the performance expectations of residents and how progress and promotion decisions are made. As well, "flex blocks" were created to help residents customize their training experience to meet their learning needs. The results of this study can be used to inform and guide implementation and adaptations in other programs and institutions.

The Assessment Burden in Competency-Based Medical Education: How Programs Are Adapting

Residents and faculty have described a burden of assessment related to the implementation of competency-based medical education (CBME), which may undermine its benefits. Although this concerning signal has been identified, little has been done to identify adaptations to address this problem. Grounded in an analysis of an early Canadian pan-institutional CBME adopter's experience, this article describes postgraduate programs' adaptations related to the challenges of assessment in CBME. From June 2019-September 2022, 8 residency programs underwent a standardized Rapid Evaluation guided by the Core Components Framework (CCF). Sixty interviews and 18 focus groups were held with invested partners. Transcripts were analyzed abductively using CCF, and ideal implementation was compared with enacted implementation. These findings were then shared back with program leaders, adaptations were subsequently developed, and technical reports were generated for each program. Researchers reviewed the technical reports to identify themes related to the burden of assessment with a subsequent focus on identifying adaptations across programs. Three themes were identified: (1) disparate mental models of assessment processes in CBME, (2) challenges in workplace-based assessment processes, and (3) challenges in performance review and decision making. Theme 1 included entrustment interpretation and lack of shared mindset for performance standards. Adaptations included revising entrustment scales, faculty development, and formalizing resident membership. Theme 2 involved direct observation, timeliness of assessment completion, and feedback quality. Adaptations included alternative assessment strategies beyond entrustable professional activity forms and proactive assessment planning. Theme 3 related to resident data monitoring and competence committee decision making. Adaptations included adding resident representatives to the competence committee and assessment platform enhancements. These adaptations represent responses to the concerning signal of significant burden of assessment within CBME being experienced broadly. The authors hope other programs may learn from their institution's experience and navigate the CBME-related assessment burden their invested partners may be facing.

Unintended consequences of technology in competency-based education: a qualitative study of lessons learned in an OtoHNS program

BACKGROUND

Formative feedback and entrustment ratings on assessments of entrustable professional activities (EPAs) are intended to support learner self-regulation and inform entrustment decisions in competency-based medical education. Technology platforms have been developed to facilitate these goals, but little is known about their effects on these new assessment practices. This study investigates how users interacted with an e-portfolio in an OtoHNS surgery program transitioning to a Canadian approach to competency-based assessment, Competence by Design.

METHODS

We employed a sociomaterial perspective on technology and grounded theory methods of iterative data collection and analysis to study this OtoHNS program's use of an e-portfolio for assessment purposes. All residents (n = 14) and competency committee members (n = 7) participated in the study; data included feedback in resident portfolios, observation of use of the e-portfolio in a competency committee meeting, and a focus group with residents to explore how they used the e-portfolio and visualize interfaces that would better meet their needs.

RESULTS

Use of the e-portfolio to document, access, and interpret assessment data was problematic for both residents and faculty, but the residents faced more challenges. While faculty were slowed in making entrustment decisions, formative assessments were not actionable for residents. Workarounds to these barriers resulted in a "numbers game" residents played to acquire EPAs. Themes prioritized needs for searchable, contextual, visual, and mobile aspects of technology design to support use of assessment data for resident learning.

CONCLUSION

Best practices of technology design begin by understanding user needs. Insights from this study support recommendations for improved technology design centred on learner needs to provide OtoHNS residents a more formative experience of competency-based training.

The Urgency of Now: Rethinking and Improving Assessment Practices in Medical Education Programs

Assessment is essential to professional development. Assessment provides the information needed to give feedback, support coaching and the creation of individualized learning plans, inform progress decisions, determine appropriate supervision levels, and, most importantly, help ensure patients and families receive high-quality, safe care in the training environment. While the introduction of competency-based medical education has catalyzed advances in assessment, much work remains to be done. First, becoming a physician (or other health professional) is primarily a developmental process, and assessment programs must be designed using a developmental and growth mindset. Second, medical education programs must have integrated programs of assessment that address the interconnected domains of implicit, explicit and structural bias. Third, improving programs of assessment will require a systems-thinking approach. In this paper, the authors first address these overarching issues as key principles that must be embraced so that training programs may optimize assessment to ensure all learners achieve desired medical education outcomes. The authors then explore specific needs in assessment and provide suggestions to improve assessment practices. This paper is by no means inclusive of all medical education assessment challenges or possible solutions. However, there is a wealth of current assessment research and practice that medical education programs can use to improve educational outcomes and help reduce the harmful effects of bias. The authors' goal is to help improve and guide innovation in assessment by catalyzing further conversations.

Knowledge and Perceptions of Competency-Based Medical Education in Diagnostic Radiology Post-Graduate Medical Education: Identifying Priorities and Developing a Framework for Professional Development Activities

Introduction: We evaluated knowledge and perceptions of an established Competency-Based Medical Education (CBME) model developed by the Royal College of Physicians and Surgeons of Canada, Competence by Design (CBD), and identified evidence-informed priorities for professional development activities (PDAs). Materials and Methods: Teaching faculty and residents at a single, large diagnostic radiology post-graduate medical education (PGME) program were eligible to participate in this cross-sectional, survey-based study. Knowledge of CBD was evaluated through multiple choice questions (MCQs), which assessed participants' understanding of major principles and terms associated with CBD. Participants' perceptions of the anticipated impact of CBD on resident education and patient care were evaluated and priorities for PDAs were identified, which informed a framework for CBD PDAs. Results: Fifty faculty and residents participated. The faculty and resident response rates were 11.6% (n = 29/249) and 55.3% (n = 21/38), respectively. The mean ± standard deviation overall score on MCQs was 39.0% ± 20.4%. The majority of participants perceived the impact of CBD on resident education to be equivocal and to not impact patient care. Knowledge of CBD was not statistically significantly associated with participants' perceptions of the impact of CBD on either resident education or patient care (P > .05). Delivery of high-quality feedback was the greatest priority identified for PDAs. Discussion: Our results and proposed CBD PDAs framework may help to guide diagnostic radiology PGME programs in designing evidence-informed PDAs, which may meaningfully contribute to the successful implementation of CBD in diagnostic radiology PGME. As diagnostic radiology PGME programs throughout the world increasingly implement CBME models, evidence-informed PDAs will become of increasing importance.

"A whole other competence story": exploring faculty perspectives on the process of workplace-based assessment of entrustable professional activities

The centrality of entrustable professional activities (EPAs) in competency-based medical education (CBME) is predicated on the assumption that low-stakes, high-frequency workplace-based assessments used in a programmatic approach will result in accurate and defensible judgments of competence. While there have been conversations in the literature regarding the potential of this approach, only recently has the conversation begun to explore the actual experiences of clinical faculty in this process. The purpose of this qualitative study was to explore the process of EPA assessment for faculty in everyday practice. We conducted 18 semi-structured interviews with Anesthesia faculty at a Canadian academic center. Participants were asked to describe how they engage in EPA assessment in daily practice and the factors they considered. Interviews were audio-recorded, transcribed, and analysed using the constant comparative method of grounded theory. Participants in this study perceived two sources of tension in the EPA assessment process that influenced their scoring on official forms: the potential constraints of the assessment forms and the potential consequences of their assessment outcome. This was particularly salient in circumstances of uncertainty regarding the learner's level of competence. Ultimately, EPA assessment in CBME may be experienced as higher-stakes by faculty than officially recognized due to these tensions, suggesting a layer of discomfort and burden in the process that may potentially interfere with the goal of assessment for learning. Acknowledging and understanding the nature of this burden and identifying strategies to mitigate it are critical to achieving the assessment goals of CBME.

Examining enablers and barriers to entrustable professional activity acquisition using the theoretical domains framework: A qualitative framework analysis study

Background

Without a clear understanding of the factors contributing to the effective acquisition of high-quality entrustable professional activity (EPA) assessments, trainees, supervising faculty, and training programs may lack appropriate strategies for successful EPA implementation and utilization. The purpose of this study was to identify barriers and facilitators to acquiring high-quality EPA assessments in Canadian emergency medicine (EM) training programs.

Methods

We conducted a qualitative framework analysis study utilizing the Theoretical Domains Framework (TDF). Semistructured interviews of EM resident and faculty participants underwent audio recording, deidentification, and line-by-line coding by two authors, being coded to extract themes and subthemes across the domains of the TDF.

Results

From 14 interviews (eight faculty and six residents) we identified, within the 14 TDF domains, major themes and subthemes for barriers and facilitators to EPA acquisition for both faculty and residents. The two most cited domains (and their frequencies) among residents and faculty were environmental context and resources (56) and behavioral regulation (48). Example strategies to improving EPA acquisition include orienting residents to the competency-based medical education (CBME) paradigm, recalibrating expectations relating to "low ratings" on EPAs, engaging in continuous faculty development to ensure familiarity and fluency with EPAs, and implementing longitudinal coaching programs between residents and faculty to encourage repetitive longitudinal interactions and high-quality specific feedback.

Conclusions

We identified key strategies to support residents, faculty, programs, and institutions in overcoming barriers and improving EPA assessment processes. This is an important step toward ensuring the successful implementation of CBME and the effective operationalization of EPAs within EM training programs.

Multicentre implementation of a nursing competency framework at a provincial scale: A qualitative description of facilitators and barriers

RATIONALE

Nurses are responsible for engaging in continuing professional development throughout their careers. This implies that they use tools such as competency frameworks to assess their level of development, identify their learning needs, and plan actions to achieve their learning goals. Although multiple competency frameworks and guidelines for their development have been proposed, the literature on their implementation in clinical settings is sparser. If the complexity of practice creates a need for context-sensitive competency frameworks, their implementation may also be subject to various facilitators and barriers.

AIMS AND OBJECTIVES

To document the facilitators and barriers to implementing a nursing competency framework on a provincial scale.

METHODS

This multicentre study was part of a provincial project to implement a nursing competency framework in Quebec, Canada, using a three-step process based on evidence from implementation science. Nurses' participation consisted in the self-assessment of their competencies using the framework. For this qualitative descriptive study, 58 stakeholders from 12 organizations involved in the first wave of implementation participated in group interviews to discuss their experience with the implementation process and their perceptions of facilitators and barriers. Data were subjected to thematic analysis.

RESULTS

Analysis of the data yielded five themes: finding the 'right unit' despite an unfavourable context; taking and protecting time for self-assessment; creating value around competency assessment; bringing the project as close to the nurses as possible; making the framework accessible.

CONCLUSION

This study was one of the first to document the large-scale, multi-site implementation of a nursing competency framework in clinical settings. This project represented a unique challenge because it involved two crucial changes: adopting a competency-based approach focused on educational outcomes and accountability to the public and valorizing a learning culture where nurses become active stakeholders in their continuing professional development.

Competency-Based Medical Education in Canadian Radiation Oncology Residency Training: an Institutional Implementation Pilot Study

Canadian radiation oncology (RO) residency programs transitioned to a competency-based medical education (CBME) training model named Competence by Design (CBD) in July 2019. Prior to this, CBD was piloted in a single RO training program to characterize assessment completion and challenges of implementation. Six residents and seven staff participated in a mixed-methods study and were oriented to CBD. Four Entrustable Professional Activities were assessed over a 4-week-long block and documented using online assessment forms. Anonymized assessments were analyzed to characterize completion. Post-pilot surveys were completed by 4/6 residents and 5/7 staff. Semi-structured post-pilot focus groups were conducted with all residents. Assessments were requested and documented on a weekly basis. Narrative comments were found in 68.1% of assessments, of which 26.7% described specific examples of observed competence or recommendations for improvement. Three of five staff believed that assessments have a negative impact on clinical workflow. Three themes were identified: (1) direct observation is the most challenging aspect of CBD to implement; (2) feedback content can be improved; and (3) staff attitude, clinical workflow, and inaccessibility of assessment forms are the primary barriers to completing assessments. This study demonstrates that CBD assessments can be completed regularly in an outpatient radiation oncology setting and that implementation challenges include improving feedback quality, promoting direct observation, and continuing faculty development to improve perceptions of this assessment model. Further study is required to identify best practices and expectations for the discipline in the era of CBME.

Overcoming the barriers to implementation of competence-based medical education in post-graduate medical education: a narrative literature review

To ensure that residents are equipped with the necessary skills for practice, competence-based medical education (CBME) represents a transformative change in postgraduate medical education, which is being progressively introduced across Canadian specialty residency programs. Successful implementation will require adjustments to curriculum, assessment, and evaluation, with careful attention to the unique needs in the local context, including resident and faculty development. This narrative review of the literature aimed to determine the potential barriers to the successful implementation of CBME and the strategies by which they can be addressed, with a specific consideration of the author's program in pediatrics in Manitoba. Eleven articles were identified with a specific focus on the implementation of CBME in the post-graduate setting, and 10 were included in the review after critical appraisal. Three key themes emerged from the articles: the value of broad stakeholder engagement and leadership, the importance of faculty and resident development, and the development of specific support systems for the educational curriculum. Different strategies were considered and contrasted for addressing these important themes. This review provides important insights and practical approaches to the barriers that should be useful as programs prepare for the implementation of CBME.

Review of Challenges to the Implementation of Competence by Design in Post-Graduate Medical Education: What Can Diagnostic Radiology Learn from the Experience of Other Specialty Disciplines?

Competence by Design (CBD) is a medical education initiative instituted by the Royal College of Physicians and Surgeons of Canada to improve the training of resident physicians in specialty disciplines. CBD integrates Competency Based Medical Education with traditional specialty discipline post-graduate medical education (PGME) training through the application of an organizational framework of competencies. Various specialty disciplines in Canada have transitioned to CBD since 2017 in a staggered approach. Diagnostic radiology PGME programs in Canada are expected to transition to CBD in 2022 for the incoming resident physician cohort. This article reviews potential challenges to the implementation of CBD in diagnostic radiology PGME programs and proposes evidence-informed targeted strategies and solutions to address these challenges. It is important for diagnostic radiology PGME programs to understand the challenges pertaining to the implementation of CBD so that they may be able to successfully implement this or similar medical education initiatives in their programs. Moreover, as radiology subspecialty PGME programs, such as nuclear medicine, interventional radiology, neuroradiology, and pediatric radiology, likewise transition to CBD and diagnostic radiology PGME programs internationally increasingly implement other Competency Based Medical Education models, the implications of the challenges pertaining to the implementation of CBD will further become of increasing importance.

Longitudinal assessment of competency development at The Ohio State University using the competency-based veterinary education (CBVE) model

With the development of the American Association of Veterinary Medical Colleges' Competency-Based Veterinary Education (CBVE) model, veterinary schools are reorganizing curricula and assessment guidelines, especially within the clinical rotation training elements. Specifically, programs are utilizing both competencies and entrustable professional activities (EPAs) as opportunities for gathering information about student development within and across clinical rotations. However, what evidence exists that use of the central tenets of the CBVE model (competency framework, milestones and EPAs) improves our assessment practices and captures reliable and valid data to track competency development of students as they progress through their clinical year? Here, we report on validity evidence to support the use of scores from in-training evaluation report forms (ITERs) and workplace-based assessments of EPAs to evaluate competency progression within and across domains described in the CBVE, during the final year clinical training period of The Ohio State University's College of Veterinary Medicine (OSU-CVM) program. The ITER, used at the conclusion of each rotation, was modified to include the CBVE competencies that were assessed by identifying the stage of student development on a series of descriptive milestones (from pre-novice to competent). Workplace based assessments containing entrustment scales were used to assess EPAs from the CBVE model within each clinical rotation. Competency progression and entrustment scores were evaluated on each of the 31 rotations offered and high-stakes decisions regarding student performance were determined by a collective review of all the ITERs and EPAs recorded for each learner across each semester and the entire year. Results from the class of 2021, collected on approximately 190 students from 31 rotations, are reported with more than 55 299 total competency assessments combined with milestone placement and 2799 complete EPAs. Approximately 10% of the class was identified for remediation and received additional coaching support. Data collected longitudinally through the ITER on milestones provides initial validity evidence to support using the scores in higher stakes contexts such as identifying students for remediation and for determining whether students have met the necessary requirements to successfully complete the program. Data collected on entrustment scores did not, however, support such decision making. Implications are discussed.

Evaluation of a competency based medical curriculum in a Sub-Saharan African medical school

BACKGROUND

Medical schools in Sub-Saharan Africa have adopted competency based medical education (CBME) to improve the quality of graduates trained. In 2015, Makerere University College of Health Sciences (MaKCHS) implemented CBME for the Bachelor of Medicine and Bachelor of Surgery (MBChB) programme in order to produce doctors with the required attributes to address community health needs. However, no formal evaluation of the curriculum has been conducted to determine whether all established competencies are being assessed.

OBJECTIVE

To evaluate whether assessment methods within the MBChB curriculum address the stated competencies.

METHODS

The evaluation adopted a cross-sectional study design in which the MBChB curriculum was evaluated using an Essential Course Evidence Form (ECEF) that was developed to collect information about each assessment used for each course. Information was collected on: (1) Assessment title, (2) Description, (3) Competency domain (4) Sub-competency addressed, (5) Student instructions, and (6) Grading method/details. Data were entered into a structured Access data base. In addition, face-to-face interviews were conducted with faculty course coordinators.

RESULTS

The MBChB curriculum consisted of 62 courses over 5 years, focusing on preclinical skills in years 1-2 and clinical skills in years 3-5. Fifty-nine competencies were identified and aggregated into 9 domains. Fifty-eight competencies were assessed at least one time in the curriculum. Faculty cited limited training in assessment as well as large student numbers as hindrances to designing robust assessments for the competencies.

CONCLUSION

CBME was successfully implemented evidenced by all but one of the 59 competencies within the nine domains established being assessed within the MBChB curriculum at MaKCHS. Faculty interviewed were largely aware of it, however indicated the need for more training in competency-based assessment to improve the implementation of CBME.

"The Most Crushing Thing": Understanding Resident Assessment Burden in a Competency-Based Curriculum

BACKGROUND

Competency-based medical education (CBME) was expected to increase the workload of assessment for graduate training programs to support the development of competence. Learning conditions were anticipated to improve through the provision of tailored learning experiences and more frequent, low-stakes assessments. Canada has adopted an approach to CBME called Competence by Design (CBD). However, in the process of implementation, learner anxiety and assessment burden have increased unexpectedly. To mitigate this unintended consequence, we need a stronger understanding of how resident assessment burdens emerge and function.

OBJECTIVE

This study investigates contextual factors leading to assessment burden on residents within the framework of CBD.

METHODS

Residents were interviewed about their experiences of assessment using constructivist grounded theory. Participants (n=21) were a purposive sample from operative and perioperative training programs, recruited from 6 Canadian medical schools between 2019 and 2020. Self-determination theory was used as a sensitizing concept to categorize findings on types of assessment burden.

RESULTS

Nine assessment burdens were identified and organized by threats to psychological needs for autonomy, relatedness, and competence. Burdens included: missed opportunities for self-regulated learning, lack of situational control, comparative assessment, lack of trust, constraints on time and resources, disconnects between teachers and learners, lack of clarity, unrealistic expectations, and limitations of assessment forms for providing meaningful feedback.

CONCLUSIONS

This study contributes a contextual understanding of how assessment burdens emerged as unmet psychological needs for autonomy, relatedness, and competence, with unintended consequences for learner well-being and intrinsic motivation.

Preparedness of Residents and Medical Students for the Transition to Competence by Design in Diagnostic Radiology Post-Graduate Medical Education

Introduction: This needs assessment evaluated residents' and medical students' knowledge of Competence by Design (CBD), perceived benefits of and challenges or barriers to the transition to CBD for residents, and perceived overall preparedness for the transition to CBD in diagnostic radiology. Materials and Methods: All diagnostic radiology residents and medical students in Canada were eligible to participate in this national cross-sectional, questionnaire-based needs assessment. Knowledge of CBD was evaluated through participants' self-reported rating of their knowledge of CBD on a 5-point Likert scale. Perceived benefits of and challenges or barriers to the transition to CBD for residents were rank ordered. Participants' overall self-reported preparedness for the transition to CBD was assessed on a 5-point Likert scale. Data were summarized by descriptive statistics and bivariate analyses were conducted as appropriate. Results: Ninety-four residents (n = 77) and medical students (n = 17) participated in this needs assessment. Participants' mean ± standard deviation self-reported rating of their overall knowledge of CBD was 2.86 ± .94. Provision of meaningful feedback to learners and learners' ability to identify their own educational needs were among the highest ranked perceived benefits of the transition to CBD, while demands on time and increased frequency of evaluation were among the highest ranked perceived challenges or barriers to the transition to CBD. Few participants reported being either "prepared" (4.7%) or "somewhat prepared" (14.0%) for the transition to CBD. Conclusion: Preparedness for the transition to CBD in diagnostic radiology may be improved. Targeted interventions to augment the preparedness of residents and medical students should be considered.

Developing a dashboard for program evaluation in competency-based training programs: a design-based research project

BACKGROUND

Canadian specialist residency training programs are implementing a form of competency-based medical education (CBME) that requires the assessment of entrustable professional activities (EPAs). Dashboards could be used to track the completion of EPAs to support program evaluation.

METHODS

Using a design-based research process, we identified program evaluation needs related to CBME assessments and designed a dashboard containing elements (data, analytics, and visualizations) meeting these needs. We interviewed leaders from the emergency medicine program and postgraduate medical education office at the University of Saskatchewan. Two investigators thematically analyzed interview transcripts to identify program evaluation needs that were audited by two additional investigators. Identified needs were described using quotes, analytics, and visualizations.

RESULTS

Between July 1, 2019 and April 6, 2021 we conducted 17 interviews with six participants (two program leaders and four institutional leaders). Four needs emerged as themes: tracking changes in overall assessment metrics, comparing metrics to the assessment plan, evaluating rotation performance, and engagement with the assessment metrics. We addressed these needs by presenting analytics and visualizations within a dashboard.

CONCLUSIONS

We identified program evaluation needs related to EPA assessments and designed dashboard elements to meet them. This work will inform the development of other CBME assessment dashboards designed to support program evaluation.

Implementation of Entrustable Professional Activities assessments in a Canadian obstetrics and gynecology residency program: a mixed methods study

BACKGROUND

Since the implementation of competency-based medical education (CBME) across residency training programs in Canada, there has been limited research understanding how entrustable professional activity (EPA) assessments are used by faculty supervisors and residents.

OBJECTIVE

This study examines how EPA assessments are used in an Obstetrics and Gynecology residency program and the impact of implementation on both groups.

METHODS

A mixed methods study design was used. Part one involved the aggregation of descriptive data of EPA assessment completion for postgraduate year 1 and 2 residents from July 2019 to May 2020. Part two involved a thematic analysis of semi-structured interviews of residents and faculty.

RESULTS

There was significant uptake of EPA assessments across community and teaching hospitals with widespread contribution of assessment data from faculty. However, both residents and faculty reported that the intended design of EPA assessments as low-stakes assessments to provide formative feedback is not how EPA assessments are experienced. Residents and faculty noted the increased level of administrative burden and related perceived stress amongst the resident group.

CONCLUSIONS

The implementation of EPA assessments is feasible across a variety of sites. However, previous measurement challenges remain. Neither residents nor faculty perceive the value of EPAs to improve feedback, despite their intended nature.

Ready, set, go! Evaluating readiness to implement competency-based medical education

PURPOSE

Organizational readiness is critical for successful implementation of an innovation. We evaluated program readiness to implement Competence by Design (CBD), a model of Competency-Based Medical Education (CBME), among Canadian postgraduate training programs.

METHODS

A survey of program directors was distributed 1 month prior to CBD implementation in 2019. Questions were informed by the R = MC² framework of organizational readiness and addressed: program motivation, general capacity for change, and innovation-specific capacity. An overall readiness score was calculated. An ANOVA was conducted to compare overall readiness between disciplines.

RESULTS

Survey response rate was 42% (n = 79). The mean overall readiness score was 74% (30-98%). There was no difference in scores between disciplines. The majority of respondents agreed that successful implementation of CBD was a priority (74%), and that their leadership (94%) and faculty and residents (87%) were supportive of change. Fewer perceived that CBD was a move in the right direction (58%) and that implementation was a manageable change (53%). Curriculum mapping, competence committees and programmatic assessment activities were completed by >90% of programs, while <50% had engaged off-service disciplines.

CONCLUSION

Our study highlights important areas where programs excelled in their preparation for CBD, as well as common challenges that serve as targets for future intervention to improve program readiness for CBD implementation.

Rivalries for attention: insights from a realist evaluation of a postgraduate competency-based medical education implementation in Canada

BACKGROUND

Implementing competency-based medical education (CBME) in post-graduate medical education (PGME) is a complex process that requires multiple systemic changes in a complex system that is simultaneously engaged in multiple initiatives. These initiatives often compete for attention during the implementation of CBME and produce unintended and unanticipated consequences. Understanding the impact of this context is necessary for evaluating the effectiveness of CBME. The purpose of the study was to identify factors, such as contexts and processes, that contribute to the implementation of CBME.

METHODS

We conducted a realist evaluation using data collected from 15 programs through focus groups with residents (2 groups, n = 16) and faculty (one group, n = 8), and semi-structured interviews with program directors (n = 18), and program administrators (n = 12) from 2018 to 2021. Data were analyzed using a template analysis based on a coding framework that was developed from a sample of transcripts, the context-mechanism-outcomes framework for realist evaluations, and the core components of CBME.

RESULTS

The findings demonstrate that simultaneous initiatives in the academic health sciences system creates a key context for CBME implementation - rivalries for attention - and specifically, the introduction of curricular management systems (CMS) concurrent to, but separate from, the implementation of CBME. This context influenced participants' participation, communication, and adaptation during CBME implementation, which led to change fatigue and unmet expectations for the collection and use of assessment data.

CONCLUSIONS

Rival initiatives, such as the concurrent implementation of a new CMS, can have an impact on how programs implement CBME and greatly affect the outcomes of CBME. Mitigating the effects of rivals for attention with flexibility, clear communication, and training can facilitate effective implementation of CBME.

Reimagining the Clinical Competency Committee to Enhance Education and Prepare for Competency-Based Time-Variable Advancement

Assessing residents and clinical fellows is a high-stakes activity. Effective assessment is important throughout training so that identified areas of strength and weakness can guide educational planning to optimize outcomes. Assessment has historically been underemphasized although medical education oversight organizations have strengthened requirements in recent years. Growing acceptance of competency-based medical education and its logical extension to competency-based time-variable (CB-TV) graduate medical education (GME) further highlights the importance of implementing effective evidence-based approaches to assessment. The Clinical Competency Committee (CCC) has emerged as a key programmatic structure in graduate medical education. In the context of launching a multi-specialty pilot of CB-TV GME in our health system, we have examined several program's CCC processes and reviewed the relevant literature to propose enhancements to CCCs. We recommend that all CCCs fulfill three core goals, regularly applied to every GME trainee: (1) discern and describe the resident's developmental status to individualize education, (2) determine readiness for unsupervised practice, and (3) foster self-assessment ability. We integrate the literature and observations from GME program CCCs in our institutions to evaluate how current CCC processes support or undermine these goals. Obstacles and key enablers are identified. Finally, we recommend ways to achieve the stated goals, including the following: (1) assess and promote the development of competency in all trainees, not just outliers, through a shared model of assessment and competency-based advancement; (2) strengthen CCC assessment processes to determine trainee readiness for independent practice; and (3) promote trainee reflection and informed self-assessment. The importance of coaching for competency, robust workplace-based assessments, feedback, and co-production of individualized learning plans are emphasized. Individual programs and their CCCs must strengthen assessment tools and frameworks to realize the potential of competency-oriented education.

Monitoring the integrity and usability of policy evaluation tools within an evolving sociocultural context: A demonstration of reflexivity using the CFPC Family Medicine Longitudinal Survey

RATIONALE, AIMS, AND OBJECTIVES

Over the last decade, policy changes have prompted Canadian medical education to emphasize a transformation to competency-based education, and subsequent development of evaluation tools. The pandemic provides a unique opportunity to emphasize the value of reflexive monitoring, a cyclical and iterative process of appraisal and adaptation, since tools are influenced by social and cultural factors relevant at the time of their development.

METHODS

Deductive content analysis of documents and resources about the advancement of primary care. Reflexive monitoring of the Family Medicine Longitudinal Survey (FMLS), an evaluation tool for physician training.

RESULTS

The FMLS tool does not explore all training experiences that are currently relevant; including, incorporating technology, infection control and safety, public health services referrals, patient preferences for care modality, and trauma-informed culturally safe care.

CONCLUSION

The results illustrate that reflection promotes the validity and usefulness of the data collected to inform policy performance and other initiatives.

Do Resident Archetypes Influence the Functioning of Programs of Assessment?

While most case studies consider how programs of assessment may influence residents’ achievement, we engaged in a qualitative, multiple case study to model how resident engagement and performance can reciprocally influence the program of assessment. We conducted virtual focus groups with program leaders from four residency training programs from different disciplines (internal medicine, emergency medicine, neurology, and rheumatology) and institutions. We facilitated discussion with live screen-sharing to (1) improve upon a previously-derived model of programmatic assessment and (2) explore how different resident archetypes (sample profiles) may influence their program of assessment. Participants agreed that differences in resident engagement and performance can influence their programs of assessment in some (mal)adaptive ways. For residents who are disengaged and weakly performing (of which there are a few), significantly more time is spent to make sense of problematic evidence, arrive at a decision, and generate recommendations. Whereas for residents who are engaged and performing strongly (the vast majority), significantly less effort is thought to be spent on discussion and formalized recommendations. These findings motivate us to fulfill the potential of programmatic assessment by more intentionally and strategically challenging those who are engaged and strongly performing, and by anticipating ways that weakly performing residents may strain existing processes.

Entrustment Decision Making in the Core Entrustable Professional Activities: Results of a Multi-Institutional Study

PURPOSE

In 2014, the Association of American Medical Colleges defined 13 Core Entrustable Professional Activities (EPAs) that all graduating students should be ready to do with indirect supervision upon entering residency and commissioned a 10-school, 5-year pilot to test implementing the Core EPAs framework. In 2019, pilot schools convened trained entrustment groups (TEGs) to review assessment data and render theoretical summative entrustment decisions for class of 2019 graduates. Results were examined to determine the extent to which entrustment decisions could be made and the nature of these decisions.

METHOD

For each EPA considered (4-13 per student), TEGs recorded an entrustment determination (ready, progressing but not yet ready, evidence against student progressing, could not make a decision); confidence in that determination (none, low, moderate, high); and the number of workplace-based assessments (WBAs) considered (0->15) per determination. These individual student-level data were de-identified and merged into a multischool database; chi-square analysis tested the significance of associations between variables.

RESULTS

The 2,415 EPA-specific determinations (for 349 students by 4 participating schools) resulted in a decision of ready (n = 997/2,415; 41.3%), progressing but not yet ready (n = 558/2,415; 23.1%), or evidence against student progression (n = 175/2,415; 7.2%). No decision could be made for the remaining 28.4% (685/2,415), generally for lack of data. Entrustment determinations' distribution varied across EPAs (chi-square P < .001) and, for 10/13 EPAs, WBA availability was associated with making (vs not making) entrustment decisions (each chi-square P < .05).

CONCLUSIONS

TEGs were able to make many decisions about readiness for indirect supervision; yet less than half of determinations resulted in a decision of readiness to perform this EPA with indirect supervision. More work is needed at the 10 schools to enable authentic summative entrustment in the Core EPAs framework.

The Importance of Professional Development in a Programmatic Assessment System: One Medical School’s Experience

The Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (CCLCM) was created in 2004 as a 5-year undergraduate medical education program with a mission to produce future physician-investigators. CCLCM’s assessment system aligns with the principles of programmatic assessment. The curriculum is organized around nine competencies, where each competency has milestones that students use to self-assess their progress and performance. Throughout the program, students receive low-stakes feedback from a myriad of assessors across courses and contexts. With support of advisors, students construct portfolios to document their progress and performance. A separate promotion committee makes high-stakes promotion decisions after reviewing students’ portfolios. This case study describes a systematic approach to provide both student and faculty professional development essential for programmatic assessment. Facilitators, barriers, lessons learned, and future directions are discussed.

An adaptation-focused evaluation of Canada's first competency-based medical education implementation in radiology

OBJECTIVES

Systematic program evaluation of the Queen's University diagnostic radiology residency program following transition to a competency-based medical education (CBME) curriculum.

METHODS

Rapid Evaluation methodology and the Core Components Framework were utilized to measure CBME implementation. A combination of interviews and focus groups were held with program leaders (n = 6), faculty (n = 10), both CBME stream and traditional stream residents (n = 6), and program staff (n = 2). Interviews and focus groups were transcribed and analyzed abductively. Study team met with program leaders to review common themes and plan potential adaptations.

RESULTS

Strengths of CBME implementation included more frequent and timely feedback as well as the role of the Academic Advisor. However, frontline faculty felt insufficiently supported with regards to the theory and practical implementation of the new curriculum and found assessment tools unintuitive. The circumstances surrounding the curricular implementation also resulted in some negative sentiment. Additional faculty and resident education workshops were identified as areas for improvement as well as changes to assessment tools for increased clarity. Residents overall viewed the changes favorably, with traditional stream residents indicating that they also had a desire for increased feedback.

CONCLUSIONS

Rapid Evaluation is an effective method for program assessment following curricular change in diagnostic radiology. A departmental champion driving enthusiasm for change from within may be valuable. Adequate resident and faculty education is key to maximize change and smooth the transition. Advances in knowledge: This study provides insights for other radiology training programs transitioning to a CBME framework and provides a structure for programmatic assessment.

A Six-Step Model for Developing Competency Frameworks in the Healthcare Professions

Competency frameworks are developed for a variety of purposes, including describing professional practice and informing education and assessment frameworks. Despite the volume of competency frameworks developed in the healthcare professions, guidance remains unclear and is inconsistently adhered to (perhaps in part due to a lack of organizing frameworks), there is variability in methodological choices, inconsistently reported outputs, and a lack of evaluation of frameworks. As such, we proposed the need for improved guidance. In this paper, we outline a six-step model for developing competency frameworks that is designed to address some of these shortcomings. The six-steps comprise [1] identifying purpose, intended uses, scope, and stakeholders; [2] theoretically informed ways of identifying the contexts of complex, "real-world" professional practice, which includes [3] aligned methods and means by which practice can be explored; [4] the identification and specification of competencies required for professional practice, [5] how to report the process and outputs of identifying such competencies, and [6] built-in strategies to continuously evaluate, update and maintain competency framework development processes and outputs. The model synthesizes and organizes existing guidance and literature, and furthers this existing guidance by highlighting the need for a theoretically-informed approach to describing and exploring practice that is appropriate, as well as offering guidance for developers on reporting the development process and outputs, and planning for the ongoing maintenance of frameworks.

Learner Phenotypes in Competency-Based Medical Education

With the launch of competency-based medical education internationally, the practical realities of implementation have failed to live up to many of the proposed theoretical benefits. Specifically, as educators we have observed a number of assessment challenges that seem directly related to identified learner phenotypes. This commentary seeks to describe these specific learner phenotypes, along with actionable recommendations for programs and their competence committees in order to overcome the associated obstacles in assessment. We describe strategies related to both the individual and program level, which can be utilized for both short-term adjustments and long-term programmatic transformation.

The use of EPA assessments in decision-making: Do supervision ratings correlate with other measures of clinical performance?

BACKGROUND

Entrustable professional activities (EPAs) have been introduced as a framework for teaching and assessment in competency-based educational programs. With growing use, has come a call to examine the validity of EPA assessments. We sought to explore the correlation of EPA assessments with other clinical performance measures to support use of supervision ratings in decisions about medical students' curricular progression.

METHODS

Spearman rank coefficients were used to determine correlation of supervision ratings from EPA assessments with scores on clerkship evaluations and performance on an end-of-clerkship-year Objective Structured Clinical Examination (CPX).

RESULTS

Both overall clinical evaluation items score (rho 0.40; n = 166) and CPX patient encounter domain score (rho 0.31; n = 149) showed significant correlation with students' overall mean EPA supervision rating during the clerkship year. There was significant correlation between mean supervision rating for EPA assessments of history, exam, note, and oral presentation skills with scores for these skills on clerkship evaluations; less so on the CPX.

CONCLUSIONS

Correlation of EPA supervision ratings with commonly used clinical performance measures offers support for their use in undergraduate medical education. Data supporting the validity of EPA assessments promotes stakeholders' acceptance of their use in summative decisions about students' readiness for increased patient care responsibility.

Eco-Normalization: Evaluating the Longevity of an Innovation in Context

PURPOSE

When initiating an educational innovation, successful implementation and meaningful, lasting change can be elusive. This elusiveness stems from the difficulty of introducing changes into complex ecosystems. Program evaluation models that focus on implementation fidelity examine the inner workings of an innovation in the real-world context. However, the methods by which fidelity is typically examined may inadvertently limit thinking about the trajectory of an innovation over time. Thus, a new approach is needed, one that focuses on whether the conditions observed during the implementation phase of an educational innovation represent a foundation for meaningful, long-lasting change.

METHOD

Through a critical review, authors examined relevant models from implementation science and developed a comprehensive framework that shifts the focus of program evaluation from exploring snapshots in time to assessing the trajectory of an innovation beyond the implementation phase.

RESULTS

Durable and meaningful "normalization" of an innovation is rooted in how the local aspirations and practices of the institutional system and the people doing the work interact with the grand aspirations and features of the innovation. Borrowing from Normalization Process Theory, the Consolidated Framework for Implementation Research, and Reflexive Monitoring in Action, the authors developed a framework, called Eco-Normalization, that highlights 6 critical questions to be considered when evaluating the potential longevity of an innovation.

CONCLUSIONS

When evaluating an educational innovation, the Eco-Normalization model focuses our attention on the ecosystem of change and the features of the ecosystem that may contribute to (or hinder) the longevity of innovations in context.

Improving Medical Education in Hematology and Transfusion Medicine in Canada: Standards and Limitations

The paradigm of medical education is evolving with the introduction of competency-based medical education (CBME) and it is crucial that residency programs adapt. In this paper, we provide an overview of the current status of medical education in Hematology in Canada including models of training, assessment methods, anticipated challenges, and the effects of the COVID-19 pandemic. We will also discuss additional training that can be pursued after a Hematology residency, with a particular focus On Transfusion Medicine as it was one of the first programs to implement a competency-based curriculum. Finally, we explore the future directions of medical education in Hematology and Transfusion Medicine.

Exploring the use of rating scales with entrustment anchors in workplace-based assessment

PURPOSE

Competency-based medical education (CBME) has prompted widespread implementation of workplace-based assessment (WBA) tools using entrustment anchors. This study aimed to identify factors that influence faculty's rating choices immediately following assessment and explore their experiences using WBAs with entrustment anchors, specifically the Ottawa Surgical Competency Operating Room Evaluation scale.

METHOD

A convenience sample of 50 semi-structured interviews with Emergency Medicine (EM) physicians from a single Canadian hospital were conducted between July and August 2019. All interviews occurred within two hours of faculty completing a WBA of a trainee. Faculty were asked what they considered when rating the trainee's performance and whether they considered an alternate rating. Two team members independently analysed interview transcripts using conventional content analysis with line-by-line coding to identify themes.

RESULTS

Interviews captured interactions between 70% (26/37) of full-time EM faculty and 86% (19/22) of EM trainees. Faculty most commonly identified the amount of guidance the trainee required as influencing their rating. Other variables such as clinical context, trainee experience, past experiences with the trainee, perceived competence and confidence were also identified. While most faculty did not struggle to assign ratings, some had difficulty interpreting the language of entrustment anchors, being unsure whether their assessment should be retrospective or prospective in nature, and if/how the assessment should change whether they were 'in the room' or not.

CONCLUSIONS

By going to the frontline during WBA encounters, this study captured authentic and honest reflections from physicians immediately engaged in assessment using entrustment anchors. While many of the factors identified are consistent with previous retrospective work, we highlight how some faculty consider factors outside the prescribed approach and struggle with the language of entrustment anchors. These results further our understanding of 'in-the-moment' assessments using entrustment anchors and may facilitate effective faculty development regarding WBA in CBME.

Developing a dashboard for faculty development in competency-based training programs: a design-based research project

BACKGROUND

Canadian specialist residency training programs are implementing a form of competency-based medical education (CBME) that requires frequent assessments of entrustable professional activities (EPAs). Faculty struggle to provide helpful feedback and assign appropriate entrustment scores. CBME faculty development initiatives rarely incorporate teaching metrics. Dashboards could be used to visualize faculty assessment data to support faculty development.

METHODS

Using a design-based research process, we identified faculty development needs related to CBME assessments and designed a dashboard containing elements (data, analytics, and visualizations) meeting these needs. Data was collected within the emergency medicine residency program at the University of Saskatchewan through interviews with program leaders, faculty development experts, and faculty participating in development sessions. Two investigators thematically analyzed interview transcripts to identify faculty needs that were audited by a third investigator. The needs were described using representative quotes and the dashboard elements designed to address them.

RESULTS

Between July 1, 2019 and December 11, 2020 we conducted 15 interviews with nine participants (two program leaders, three faculty development experts, and four faculty members). Three needs emerged as themes from the analysis: analysis of assessments, contextualization of assessments, and accessible reporting. We addressed these needs by designing an accessible dashboard to present contextualized quantitative and narrative assessment data for each faculty member.

CONCLUSIONS

We identified faculty development needs related to EPA assessments and designed dashboard elements to meet them. The resulting dashboard was used for faculty development sessions. This work will inform the development of CBME assessment dashboards for faculty.

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?

Outcomes of competency-based medical education: A taxonomy for shared language

As the global transformation of postgraduate medical training continues, there are persistent calls for program evaluation efforts to understand the impact and outcomes of competency-based medical education (CBME) implementation. The measurement of a complex educational intervention such as CBME is challenging because of the multifaceted nature of activities and outcomes. What is needed, therefore, is an organizational taxonomy to both conceptualize and categorize multiple outcomes. In this manuscript we propose a taxonomy that builds on preceding works to organize CBME outcomes across three domains: focus (educational, clinical), level (micro, meso, macro), and timeline (training, transition to practice, practice). We also provide examples of how to conceptualize outcomes of educational interventions across medical specialties using this taxonomy. By proposing a shared language for outcomes of CBME, we hope that this taxonomy will help organize ongoing evaluation work and catalyze those seeking to engage in the evaluation effort to help understand the impact and outcomes of CBME.

From Utopia Through Dystopia: Charting a Course for Learning Analytics in Competency-Based Medical Education

The transition to the assessment of entrustable professional activities as part of competency-based medical education (CBME) has substantially increased the number of assessments completed on each trainee. Many CBME programs are having difficulty synthesizing the increased amount of assessment data. Learning analytics are a way of addressing this by systematically drawing inferences from large datasets to support trainee learning, faculty development, and program evaluation. Early work in this field has tended to emphasize the significant potential of analytics in medical education. However, concerns have been raised regarding data security, data ownership, validity, and other issues that could transform these dreams into nightmares. In this paper, the authors explore these contrasting perspectives by alternately describing utopian and dystopian futures for learning analytics within CBME. Seeing learning analytics as an important way to maximize the value of CBME assessment data for organizational development, they argue that their implementation should continue within the guidance of an ethical framework.

Key considerations in planning and designing programmatic assessment in competency-based medical education

Programmatic assessment as a concept is still novel for many in clinical education, and there may be a disconnect between the academics who publish about programmatic assessment and the front-line clinical educators who must put theory into practice. In this paper, we clearly define programmatic assessment and present high-level guidelines about its implementation in competency-based medical education (CBME) programs. The guidelines are informed by literature and by lessons learned from established programmatic assessment approaches. We articulate five steps to consider when implementing programmatic assessment in CBME contexts: articulate the purpose of the program of assessment, determine what must be assessed, choose tools fit for purpose, consider the stakes of assessments, and define processes for interpreting assessment data. In the process, we seek to offer a helpful guide or template for front-line clinical educators. We dispel some myths about programmatic assessment to help training programs as they look to design-or redesign-programs of assessment. In particular, we highlight the notion that programmatic assessment is not 'one size fits all'; rather, it is a system of assessment that results when shared common principles are considered and applied by individual programs as they plan and design their own bespoke model of programmatic assessment for CBME in their unique context.

Becoming a deliberately developmental organization: Using competency based assessment data for organizational development

Medical education is situated within health care and educational organizations that frequently lag in their use of data to learn, develop, and improve performance. How might we leverage competency-based medical education (CBME) assessment data at the individual, program, and system levels, with the goal of redefining CBME from an initiative that supports the development of physicians to one that also fosters the development of the faculty, administrators, and programs within our organizations? In this paper we review the Deliberately Developmental Organization (DDO) framework proposed by Robert Kegan and Lisa Lahey, a theoretical framework that explains how organizations can foster the development of their people. We then describe the DDO's conceptual alignment with CBME and outline how CBME assessment data could be used to spur the transformation of health care and educational organizations into digitally integrated DDOs. A DDO-oriented use of CBME assessment data will require intentional investment into both the digitalization of assessment data and the development of the people within our organizations. By reframing CBME in this light, we hope that educational and health care leaders will see their investments in CBME as an opportunity to spur the evolution of a developmental culture.

Re-examining the value proposition for Competency-Based Medical Education

The adoption of competency-based medical education (CBME) by Canadian postgraduate training programs has created a storm of excitement and controversy. Implementing the system-wide Competency by Design (CBD) project initiated by the Royal College of Physicians & Surgeons of Canada (RCPSC), is an ambitious transformative change challenge. Not surprisingly, tensions have arisen across the country around the theoretical underpinnings of CBME and the practicalities of implementation, resulting in calls for evidence justifying its value. Assumptions have been made on both sides of the argument contributing to an atmosphere of unhealthy protection of the status quo, premature conclusions of CBME's worth, and an oversimplification of risks and costs to participants. We feel that a renewed effort to find a shared vision of medical education and the true value proposition of CBME is required to recreate a growth-oriented mindset. Also, the aspirational assertion of a direct link between CBME and improved patient outcomes requires deferral until further implementation and study has occurred. However, we perceive more concrete and immediate value of CBME arises from the societal contract physicians have, the connection to maintaining self-regulation, and the potential customization of training for learners.