Chair's Column: Competence by Design: A Threat or an Opportunity?

There is a lot happening right now in the academic medicine environment, not least of which is the impending formal implementation of the new Competency by Design (CBD) framework for our residents.

In case you haven’t heard, CBD is the Royal College’s initiative to, “improve physician training and lifelong learning,” to, “transition specialist medical education from a traditional time-based model to a hybrid form of competency-based medical education (CBME).” ”CBD focuses on outcomes — organizes physician training around desired outcomes and looks at the needed competencies.” Brian Wong pointed out to me, the Frenk Lancet report on CBME published in the Lancet in 2010* clearly articulated that the main driver for CBME is to improve patient outcomes and these desired patient and health system outcomes determine the competencies physicians need to achieve these outcomes. To quote Brian, “…the most exciting part of CBME, if done well, is that it has the potential to shift learning from being solely learner centered, to being more patient centered."

CBME comes with a new lexicon. In place of our current methods of resident evaluation, we will assess residents’ achievement of educational ‘milestones,’ defined as, “observable markers of someone’s ability along a developmental continuum,” and competency to perform ‘entrustable professional activities’ or EPAs. From the Royal College, an EPA is, “a task in the clinical setting that a supervisor can delegate to a resident who has demonstrated sufficient competence. Typically, an EPA integrates multiple milestones. They are the tasks that must be accomplished, whereas milestones refer to the individual’s abilities.” If I have it right, an example of a milestone might be to be able to take a thorough history of a patient with multiple chronic conditions, while the EPA might be to develop and execute, with the patient, a treatment plan for condition X in the setting of multiple other conditions.

Well, I am by no means an education scholar, nor any kind of expert on CBD/CBME, but what I have learned about it thus far actually has me pretty excited and, frankly, optimistic that this will be good for us all – our faculty, our trainees and most importantly, our patients. However, I know not everyone shares my enthusiasm. So, I thought I would take this opportunity to tell you why I am positive about CBME, and what I am hearing from the experts.

A while ago, I spoke about my experiences in Addis Ababa with several of our hematology faculty, where we sat in and observed ALL trainee-patient interactions. I reflected on how much more gratifying it was to be able to play a hands-on role in working alongside the trainee as they took the history from the patient, examined them, formulated and relayed their opinions and treatment plan to the patient. I watched our own Gena Piliotis – a brilliant master clinician and teacher - gently guide the resident during the consultation. When it was clear that the resident was missing the forest for the trees or heading off on a perilous tangent, she would interject and ask simply, “You asked about X – tell me what you are thinking?” It was fantastic! To me, this was CBD in action! At point of care, learning was happening – and the patient was part of it!

But, clearly, we are not in Addis Ababa and, while I think there is a lot we can learn from these experiences, how CBME rolls out here will undoubtedly look different.

I spent a few days last week in Ottawa at CAPM – the Canadian Association for Professors of Medicine (i.e. the Chairs of Medicine across Canada). I learned, not surprisingly, that there is universal angst about the transition to CBD. We heard a terrific presentation on CBME from Dr. Ken Harris, Executive Director in the Office of Specialty Education at the Royal College. He explained that a major driver for the shift to CBME is the hope that with much more regular and frequent evaluations designed to guide the trainee towards achieving each milestone, and ultimately the EPAs, there will be a greater willingness - both on the part of faculty members and trainees — to engage in meaningful conversations about residents’ performance. I see this also as an opportunity ultimately, to reflect on and talk about how to make knowledgeable, skillful and compassionate doctors. Is there any evidence that this will be the case? Is there evidence that this will help us produce more competent physicians? No, not exactly, but is there anyone who doesn’t think we could be doing a better job of resident evaluation?    

There is currently such pressure – real and imagined – to give every trainee a high rating, even when undeserved. A faculty member’s annual review, likelihood of being recognized as an excellent teacher, and promotion through the ranks are very much tied to their evaluations as a teacher and, whether we like it or not, a teacher who is critical of a trainee is at risk of receiving a bad evaluation. From the resident’s perspective, a subspecialty training spot, admission to a graduate program, or even possibly a job, might be perceived as ‘on the line’ if their performance is anything but stellar! What is wrong with ‘meeting expectations?’ If CBME has potential to lead to more meaningful and timely feedback to our trainees, then that can only be good.

Two of the department’s strategic foci are to ensure the patient is at the centre of all we do, and to align our training with the future needs of the population. I see CBD as a potential vehicle by which to accomplish these goals.

Let me explain why.

First, by nature of the evaluation structure for CBD, it will be incumbent on our faculty to spend more time with our trainees and patients at point of care, whether at the bedside or in clinic. My understanding is that this doesn’t mean that the faculty member will be required to sit in for the duration of the entire interaction, but rather to provide sufficient and regular ‘spot checks’ to ensure milestones are being met and, ultimately, that EPAs are achieved. While this is, in my opinion, a good thing — more time for teaching at point of care —where do any of our teachers find this time? We understand that CBD cannot simply be laid on top of everything you are already doing! For CBME to work, we must stop doing some things. What do we give up? It would be great to hear from those of you who are current residents and faculty members – what do you think?

Second, while I am a proponent of the CanMEDS framework, I find the chopping up of the core competencies into distinct constructs doesn’t always translate well to teaching physicians how to care for patients. Too often, in my opinion, the ‘intrinsic’ competencies** – communicator, advocate, collaborator and even leader, may be over-shadowed by the traditional ‘medical expert’ focus of medical education and, as a result, relegated to discussions at academic half day or noon-time lectures rather than at point of care. CBD presents us the opportunity to change this – to take a more holistic approach to medical training that, through increased interactions between learners, teachers and patients at point of care, allows us to explore ALL aspects of being a physician in a more comprehensive manner.

Third, related to my second point above, when one has relatively limited time with any one trainee, it can be very difficult to complete the POWER evaluation. There hasn’t been enough time to really get to know the resident (a bigger problem in the ER and ambulatory settings than perhaps in in-patient care). Again, I think CBME may help. I imagine that it might be quite intuitive to answer the question, “Is this trainee ready to do X (rheumatology consult, joint injection, etc.) on their own?” Or, “Would I want this physician treating my family members?” after a day working with them? It’s akin to recognizing when a medicine trainee fully understands when a patient is ‘sick.’ This understanding is fundamental in internal medicine – it determines the speed of action required to manage the patient and can be critical to whether a patient lives or dies – it also to a great extent determines when faculty become comfortable ‘entrusting’ the resident with the care of such patients. When I think about CBME in this frame, it makes a lot of sense! Until a resident can consistently take a detailed history, without missing key points, they aren’t ready to be independent consultants. And those that have difficulty communicating with patients in an empathetic manner – even in stressful situations – aren’t the ones I would want caring for my family members. Inherently, this makes sense.

For these reasons, I am excited and optimistic about CBME, but want to ensure that we have the infrastructure, professional development, and time structure in place to ensure its success. Fundamental to the success of CBD are the following:

1. Time – we must free up precious time to enable more point of care teaching opportunities;

2. Simplicity – the evaluation framework we put in place should be as simple as possible and speak to what we all recognize as a “great physician;”

3. Faculty buy-in – CBME will require willingness on the part of our teachers to evaluate trainees honestly, fairly and constructively;

4. Trainee buy-in – CBME will also require openness on the part of our residents to receive constructive – and frequent – feedback on their performance as physicians. All feedback, if useful, cannot be positive – but it can all be constructive.

As always, the devil will be in the details, but we are in really good hands. The challenge with implementing CBD is to do so in a way that provides new opportunities for dialogues between trainees and faculty around the development of clinical expertise and enhances the department’s tradition of excellence and innovation in education. In other words, the aim is to improve upon past success while putting a unique U of T stamp on Competency by Design. Many of our faculty members have been leading the CBD/CBME charge at the Royal College, and our Vice-Chair, Education, Arno Kumagai, has hit the deck running. Soon, he will be posting a new leadership position in the department - a faculty lead for CBME. Interested candidates are encouraged to contact Dr. Kumagai.

As always, let us know what you think about all this – all suggestions are welcome!

*Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010

**Sherbino J, Frank JR, Flynn L, Snell L. Intrinsic Roles" rather than "armour": renaming the "non-medical expert roles" of the CanMEDS framework to match their intent. Adv Health Sci Educ Theory Pract 2011 Dec;16(5):695-7.