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Competency-based Medical Education
'The greatest
  obstacle to
  discovery is not
  ignorance, it is
  the illusion of
  knowledge’
          - Daniel J.
            Boorstin
What has been
the history of
competency-
based education
in your
department,
division or
clinical
education?
OVERVIEW
Definitions
Models
Benefits & Challenges
Examples in Practice
• Lessons learned
C O M P E T E N C Y-
PREVIOUSL
                           BASED
Y
                           E D U C AT I O N
Apprenticeship +           • Competency is an
  Knowledge = Training       outcome

• Evaluation focused on    • Standardization of
  knowledge, some skills     outcomes with the
• Knowledge drove the        flexibility in how
  curriculum design          learners achieve
  process                    these
HISTORY OF COMPETENCY-BASED MED ED

“…by using competencies as an organizing
  framework, educators have an opportunity to
  address these issues by designing learning
  experiences that continuously incorporate prior
  learning elements and emphasize observable
  abilities.”


                (McGaghie 1978; Voorhees 2001a; Carraccio et al. 2002)
MODEL: CANMEDS COMPETENCIES
ACGME
Competency-based Medical Education
Competency-based Medical Education
PATIENT CARE

Provide patient care that is compassionate, appropriate, and effective for
   the treatment of health problems and the promotion of health.
MEDICAL KNOWLEDGE

Demonstrate knowledge of established and evolving
  biomedical, clinical, epidemiological and social-behavioral sciences, as
  well as the application of this knowledge to patient care.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Demonstrate the ability to investigate and evaluate their care of patients, to
  appraise and assimilate scientific evidence, and to continuously
  improve patient care based on constant self-evaluation and life-long
  learning.
INTERPERSONAL AND COMMUNICATION SKILLS
Demonstrate interpersonal and communication skills that result in the
  effective exchange of information and collaboration with patients, their
  families, and health professionals.
PROFESSIONALISM
Demonstrate a commitment to carrying out professional responsibilities
  and an adherence to ethical principles.
SYSTEMS-BASED PRACTICE
Demonstrate an awareness of and responsiveness to the larger context and
  system of health care, as well as the ability to call effectively on other
  resources in the system to provide optimal health care.
Competency-based Medical Education
PEDIATRICS
EMERGENCY MEDICINE
DEFINITIONS
Competency
   What a person can do upon completion of
  training


Objective
  What a student should be able to do at the end
  of a single learning experience
COMPETENCIES & OBJECTIVES
“Competency is an observable ability of a health professional, integrating
   multiple components such as knowledge, skills, values and attitudes.
   Since competencies are observable, they can be measured and
   assessed to assure their acquisition. Competencies can be assembled
   like building blocks to facilitate progressive development.”
ENTRUSTABLE PROFESSIONAL ACTIVITIES (EPA)

1. Identify the principal clinical responsibilities in a particular
   medical specialty

2. Map these clinical responsibilities to core competencies most
   important to each responsibility. These are the EPAs
                                  ten Cate & Scheele, 2007; ten Cate, 2011
ENTRUSTABLE PROFESSIONAL ACTIVITIES (EPA)

3. Allow progressive independence of the resident to perform the
   EPA without direct supervision
                              ten Cate & Scheele, 2007; ten Cate, 2011
EPA FOR PEDS
HOW DO YOU KNOW WHEN TO TRUST?
• Trustworthiness: knowledge &
  skill, discernment, conscientiousness, truthfulness
  (Kennedy et al, 2008)
• Self-assessment in action: slowing down, seeking help
  (Eva et al, 2005)
• Global evaluations identify difficulties, not trust (Williams
  et al, 2003)
• In-training exam, OSCE, mini-CEX tangential to integrated
  professional functions
  (Jones, Rosenberg, Gilhooly, Carraccio, 2011)
• Close resident-faculty relationship in longitudinal
  settings proposed as best
  (Jones, Rosenberg, Gilhooly, Carraccio, 2011)
MODEL: COMPETENCY DEVELOPMENT
                                                             Requires:
                                                             Time
                                                             Self-Awareness
                                                             Mentorship
                                                             Access to resources




              Dr. Will Taylor, National College of Natural
              Medicine, Portland, Oregon; 2007
Competency-based Medical Education
BENEFITS
•   Focuses on learner’s development (needs)
•   Promotes continuum of expertise development and/or education
•   De-emphasize time-based training
•   Potentially more portable training
•   Challenges community to discourse on physician competence
•   Conceptualizes assessment as a formative and summative tool
•   Measurable outcomes lead to fulfilling social contract
CHALLENGES
•   Reductionism
•   Lowest common denominator – bar to step over, not jump over & to
    next opportunities
•   Overemphasis on outcomes (what about apprenticeship?)
•   Logistical/scheduling chaos
•   Resources needed
•   Instructional design knowledge and/or educational technologies needed
Competency-based Medical Education
Competency-based Medical Education
CASE STUDIES
RESIDENCY & COMPETENCIES
“PGME would benefit from a matrix educational
  model that further retains the professional
  maturation elements of the apprenticeship model
  while integrating a competency-based model that
  includes explicit expectations and assessment yet
  being cautious and avoiding the risk of
  deconstruction of practice into ever smaller units of
  competence or of focusing on only those
  competencies that are easy to describe and
  assess.”
                - Association of Faculties of Medicine of Canada, 2011

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Competency-based Medical Education

  • 2. 'The greatest obstacle to discovery is not ignorance, it is the illusion of knowledge’ - Daniel J. Boorstin
  • 3. What has been the history of competency- based education in your department, division or clinical education?
  • 5. C O M P E T E N C Y- PREVIOUSL BASED Y E D U C AT I O N Apprenticeship + • Competency is an Knowledge = Training outcome • Evaluation focused on • Standardization of knowledge, some skills outcomes with the • Knowledge drove the flexibility in how curriculum design learners achieve process these
  • 6. HISTORY OF COMPETENCY-BASED MED ED “…by using competencies as an organizing framework, educators have an opportunity to address these issues by designing learning experiences that continuously incorporate prior learning elements and emphasize observable abilities.” (McGaghie 1978; Voorhees 2001a; Carraccio et al. 2002)
  • 11. PATIENT CARE Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
  • 12. MEDICAL KNOWLEDGE Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.
  • 13. PRACTICE-BASED LEARNING AND IMPROVEMENT Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
  • 14. INTERPERSONAL AND COMMUNICATION SKILLS Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.
  • 15. PROFESSIONALISM Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
  • 16. SYSTEMS-BASED PRACTICE Demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.
  • 20. DEFINITIONS Competency What a person can do upon completion of training Objective What a student should be able to do at the end of a single learning experience
  • 21. COMPETENCIES & OBJECTIVES “Competency is an observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes. Since competencies are observable, they can be measured and assessed to assure their acquisition. Competencies can be assembled like building blocks to facilitate progressive development.”
  • 22. ENTRUSTABLE PROFESSIONAL ACTIVITIES (EPA) 1. Identify the principal clinical responsibilities in a particular medical specialty 2. Map these clinical responsibilities to core competencies most important to each responsibility. These are the EPAs ten Cate & Scheele, 2007; ten Cate, 2011
  • 23. ENTRUSTABLE PROFESSIONAL ACTIVITIES (EPA) 3. Allow progressive independence of the resident to perform the EPA without direct supervision ten Cate & Scheele, 2007; ten Cate, 2011
  • 25. HOW DO YOU KNOW WHEN TO TRUST? • Trustworthiness: knowledge & skill, discernment, conscientiousness, truthfulness (Kennedy et al, 2008) • Self-assessment in action: slowing down, seeking help (Eva et al, 2005) • Global evaluations identify difficulties, not trust (Williams et al, 2003) • In-training exam, OSCE, mini-CEX tangential to integrated professional functions (Jones, Rosenberg, Gilhooly, Carraccio, 2011) • Close resident-faculty relationship in longitudinal settings proposed as best (Jones, Rosenberg, Gilhooly, Carraccio, 2011)
  • 26. MODEL: COMPETENCY DEVELOPMENT Requires: Time Self-Awareness Mentorship Access to resources Dr. Will Taylor, National College of Natural Medicine, Portland, Oregon; 2007
  • 28. BENEFITS • Focuses on learner’s development (needs) • Promotes continuum of expertise development and/or education • De-emphasize time-based training • Potentially more portable training • Challenges community to discourse on physician competence • Conceptualizes assessment as a formative and summative tool • Measurable outcomes lead to fulfilling social contract
  • 29. CHALLENGES • Reductionism • Lowest common denominator – bar to step over, not jump over & to next opportunities • Overemphasis on outcomes (what about apprenticeship?) • Logistical/scheduling chaos • Resources needed • Instructional design knowledge and/or educational technologies needed
  • 33. RESIDENCY & COMPETENCIES “PGME would benefit from a matrix educational model that further retains the professional maturation elements of the apprenticeship model while integrating a competency-based model that includes explicit expectations and assessment yet being cautious and avoiding the risk of deconstruction of practice into ever smaller units of competence or of focusing on only those competencies that are easy to describe and assess.” - Association of Faculties of Medicine of Canada, 2011