Educating and training the next generation of physicians – for academia and community – is likely the most noble obligation of any academic physician. During the past decades medical education has emancipated itself from an apprenticeship type of supervised learning-by-doing and emulating-a-role-model (that was supposed to be the professor) to a pedagogical enterprise of its own. This comes of course with its inherent ups and downs, twists and fashions, the perception of which depend among others on one’s own past learning experiences.
I started medical training at a time when the “master” (the professor) decided based on his (almost never her) perception of the trainee’s performance in an oral/practical exam whether and when the trainee was competent. Soon after I had started, this was discredited as entirely subjective (which it was) and everything shifted towards written multiple choice type exams with identical questions to be answered by trainees, such as myself, at the same time around the entire system, and graded according to objective statistical criteria. While this may be able to somewhat objectively assess knowledge, skills, both professional and interpersonal, can hardly be assessed that way – and these skills are at least as important for a physician caring for patients as the knowledge about diseases. The OSCE type standardized practical exams were therefore added in an attempt to more objectively assess knowledge and skills in a simulated practical clinical situation. But actors are not patients and OSCEs remain a somewhat artificial onetime event distant from a physician’s daily practice setting. Today, we have come almost full circle with a worldwide movement towards so called competency based education or Competency by Design (CBD) to use the Royal College’s branding term.
What is CBD and what does it aim for? Well, the ultimate goal of CBD, as that of any serious medical education, is to train physicians that are competent in delivering the services they are expected to deliver in their practice, i.e. have all the knowledge, professional, and interpersonal skills required to perform all the tasks they are expected to serve the public with. That’s the Good, hard to disagree on this one, isn’t it?
In what does CBD then differ from the current and past educational paradigms? Well, current and past paradigms are largely based on time spent in specific courses/rotations; but there are faster and slower learners. Current/previous systems offer limited opportunity to further the faster learners beyond what has been established as the minimal standard learning aims and to help the slower ones achieving the required goals in time. Competency based education in its pure form, defines broad tasks that a professional needs to be able to independently master in order to competently provide the service he/she is expected to provide in his/her future practice (so called entrustable professional activities or EPAs); these are composed of several smaller building blocks (or milestones). Once a trainee has demonstrated in several (directly to indirectly) observed instances to be competent in an EPA, he/she moves on to the next one, irrespective of the time required to reach the competency level. Of course, this completely time independent, pure competency based education paradigm makes scheduling difficult and may create conflicts with service needs – and that’s the Bad.
The Royal College’s brand of competency based education, CBD, takes this into account and effectively is a hybrid which adopts the principles of competency based education, i.e. milestones and EPAs, but maintains the PGY time structure. Groups of EPAs are arranged in sequence starting with introduction to discipline and ranging up to transition to practice. Thus, if, let’s say, a PGY1 resident has fulfilled all his/her required milestones and EPA’s already after 6 months, he/she will be remain a PGY1 resident for service purposes, but will be given additional learning tasks.
Sounds great on paper, you may say, but how will this translate into my busy daily practice where I am already stretched beyond tolerable levels and pulled in different directions by ever increasing service and academic demands? The repetitive observations and assessments required in CBD will add further to my work load, but I simply cannot deliver more; and neither our health care system nor the university has signaled increases to resources. So how to cope? Moreover, what is broken and what are we trying to fix with CBD? Most importantly, how do we assess success or failure of this major restructuring of our medical education system?
While those questions – the Ugly – are all well taken, they seem to me to miss the point. Fact is that the CBD train has long left the station. It will come our way regardless of whether we want it or not. Never fight the problem, solve it! The point is how to implement CBD without negatively affecting the quality of service delivery and with the resources we control in our Department, and acknowledging that some reallocation of resources towards CBD will be required.
We are not alone in tackling the tasks associated with CBD implementation, departments in the College of Medicine, and at the Departments of Medicine at Universities across the country face similar challenges. Let’s become engaged and learn from those who are ahead of us. Let’s refrain from trying to re-invent the wheel, let’s use our energy to learn from the experiences of others and make it better. And most importantly, let’s be present at the tables of the various Royal College subspecialty committees where planning of CBD role out in the different subspecialties happens. It is mandatory that our PGME directors attend these meetings. If our seat is empty at those tables, we forfeit our opportunity to contribute to shaping the future – which is inexcusable and inacceptable! We all want the Good to prevail, let’s do it – together!