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Competency-based Medical Education

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Competency-based education has been a concept in medical education since the 1970s, though has only gained traction and application in programs in the last 15-20 years. Multiple competency models exist (e.g. CANMeds, ACGME), though ACGME is prevalent in the US and is the focus of this presentation. The most common tensions in the competency-based education movement exist around: the deconstruction of clinical practice over respect for the complexity of the tasks; the challenge of appropriate assessments; and when to know to trust a resident with increasing responsibilities. The benefits and challenges are discussed; the session closes with an exploration of three case studies, drawing from different geographical regions (US, Canada, Australia), as a way to help participants appreciate the issues in implementating competency-based education in residency programs.

Prepared for and presented to Teaching Scholars Program, University of Colorado School of Medicine, Dec 18, 2012. Available under Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. References used within the presentation available upon request - email author please.

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Competency-based Medical Education

  1. 1. 'The greatest obstacle to discovery is not ignorance, it is the illusion of knowledge’ - Daniel J. Boorstin
  2. 2. What has been the history of competency- based education in your department, division or clinical education?
  3. 3. OVERVIEW Definitions Models Benefits & Challenges Examples in Practice • Lessons learned
  4. 4. 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
  5. 5. 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)
  6. 6. MODEL: CANMEDS COMPETENCIES
  7. 7. ACGME
  8. 8. PATIENT CARE Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
  9. 9. 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.
  10. 10. 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.
  11. 11. 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.
  12. 12. PROFESSIONALISM Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
  13. 13. 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.
  14. 14. PEDIATRICS
  15. 15. EMERGENCY MEDICINE
  16. 16. 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
  17. 17. 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.”
  18. 18. 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
  19. 19. 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
  20. 20. EPA FOR PEDS
  21. 21. 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)
  22. 22. MODEL: COMPETENCY DEVELOPMENT Requires: Time Self-Awareness Mentorship Access to resources Dr. Will Taylor, National College of Natural Medicine, Portland, Oregon; 2007
  23. 23. 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
  24. 24. 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
  25. 25. CASE STUDIES
  26. 26. 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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