Hamad Medical Corporation (HMC) was recently awarded Institutional Accreditation by the Accreditation Council for Graduate Medical Education International (ACGME-I). The next step will be the accreditation of Specialty and Subspecialty programs. This is occurring at a time when the ACGME is shifting from Process Based to Competency Based Graduate Medical Education (GME) Programs(1).
It takes a lot to be an expert physician, but the one attribute that is likely the most important is also the hardest to define, measure, and predict. That one attribute, which more than any other, differentiates the truly excellent from the adequate is professionalism. But how do we measure it? Or more importantly, for many of us in the education community, how do we predict it?
What is Competency Based Medical Education?
Competency based Medical Education (CBME) focuses on Educational Outcomes. Therefore competency based GME (CBGME) must demonstrate that a graduating resident will be competent in the 6 ACGME competency domains:
- Medical Knowledge (MK)
- Patient Care (PC)
- Practice Based Learning and Improvement (PBLI)
- Interpersonal and Communication Skills (ICS)
- Professionalism (P)
- System Based Practice (SBP)
CBGME explicitly defines the desired Resident abilities and allows those defined outcomes to guide the development of the Curriculum, Assessment and Program Evaluation. The International CBME collaboration proposed the following definitions (2):
- Competence: Is the array of abilities across multiple domains of physician performance, in a certain context. Statements about competence require descriptive qualifiers to define the relevant abilities, context and stage of training. Competence is multidimensional and dynamic. It changes with time, experience and setting.
- Competency: Is an observable ability of a Health Professional, integrating Knowledge, Skills and Attitudes . Since Competencies are observable, they can then be measured and assessed to ensure their acquisition.
- Competent : Is possessing the required abilities in all domains in a certain context, at a defined stage of Medical Education or practice.
Progression of Competence
Competence does not remain static, but is progressive and dynamic. Progression in GME requires that the Resident demonstrate competence at defined Stages of development that the ACGME call “Milestones”.
The Milestones describe behaviors that can be observed and assessed by trained Faculty at significant stages of development, that when met, allow the Faculty to know that the Resident is ready to progress to the next stage (3).
Assessment in Competency Based GME
Competency Based GME requires assessment to occur at the top of Millers Pyramid (4), which is assessment of clinical performance. This can only be accomplished by direct observation during delivery of patient care. The Assessment of competencies that are observable behaviors requires a close relationship between the Faculty and the Residents in the work environment were learning occurs (5), this Formative assessment is an important characteristic of CBGME. It improves the validity of assessment by bringing assessment to the authentic clinical environment and aligns what we measure with what the resident does in the workplace. It also improves the Reliability of assessment, by frequent sampling of Residents’ clinical performance by multiple Faculty assessors.
Workplace Assessment also ensures patient safety and appropriate patient care, as the level of supervision of Residents, will depend on the assessed competency of the Resident. In this way, Residents are given progressive responsibility for patient care, following assessment by Faculty ensuring that the Resident has attained the competencies necessary to perform the required task, at this stage of training, contributing to the professional development of the Resident (6).
An essential role of the Faculty during the continuous work based assessment of competencies is to deliver timely Feedback to the Resident. As the feedback will be immediately relevant to the Resident, leading to an immediate improvement of competencies. Recent evidence suggests that acceptance and incorporation of feedback to learning are dependent on the receiver’s perception of the giver’s investment in his professional development, which occurs when both work in a close relationship (7).
The Comparison of the elements of structure and process based versus competency based educational programs are shown in the Table 1 (8). Carraccio and Englander (9), Reflecting on a decade and the journey ahead for CBME, describe best how successful adoption of CBME will look like.
- We will have a standardized language and desired competencies, so that we share a clear mental model of the trajectory to become the “Expert” physician.
- We will backward vision the most effective and efficient path for curriculum design and equip ourselves with evidence based learning strategies.
- We will have built “Rest Stops” along the way for assessment and guided reflection.
- The assessment tools will embrace the complexity of care delivery and focus on what is meaningful and target it for formative assessment.
- We will directly observe learners, from early in the process. Learners will develop relationships with patients, mentors and team members, which will reinforce professionalism and accountability.
In Conclusion, The changes imposed by a Competency Based GME will take time to be adopted and will require continuous evaluation of the programs and appropriate solutions to the challenges that will inevitably occur.
|A Comparison of the elements of Process- based versus Competency- based Programs
||Learner and Teacher-driven
||Analysis of Behaviors
||Synthesis of Behaviors
|Setting of assessment
|Timing of assessment
||Formative with Feedback
|Completion of Program
Table 1: Modified From Carraccio et al. Shifting Paradigms: From Flexner to Competence. Acad Med 2002; 77:361-367.p362
For further reading on this topic, consider:
- Nasca T,Philibert I,Brigham T,Flynn T. The Next GME Accreditation System: Rationale and Benefits. N Engl J Med. 2012;366:1051-1056.
- Frank J,Snell L,Cate OT,Holmboe E, Carraccio C , et al. Competency Based Medical Education: Theory to Practice. Med Teach. 2010; 32:638-645.
- Nasca T, The next Step in the Outcomes based Accreditation Project. ACGME Bulletin. 2008, 2-14.
- Miller G. The Assessment of Clinical Skills/Competence/Performance. Acad Med. 1990; 65(Suppl 9) : S63-S65.
- Van Der Vleuten C. The Assessment of Professional Competence: Developments in Research and Practical Implications. Adv Health Sci Educ. 1996; 1: 41-46
- Iobst W,Sherbina J, Cate OT, Richardson D, et al. Competency Based Medical Education in Post Graduate Medical Education. Med Teach. 2010;32:651-656.
- Watlinge C, Driessen E, Van Der Vleuten C,Vanstone M, Lingard I. Understanding Responses to Feedback: The Potential and Limitations of Regulatory Focus Theory . Med Educ .2012; 46: 593-603.
- Corraccio C , Wolfsthal S,Englander R,Ferentz K, Martin C. Shifting Paradigms: From Flexner to Competencies. Acad Med.2002;77:361-367.
- Carraccio C, Englander R. From Flexner to Competencies: Reflections on a Decade and the Journey Ahead.Acad Med.2013;88:1067-1073.
Reviewed for November 2013 by
Ismail Helmi, MD, Med.
Deputy Director, Department of Medical Education,
Hamad Medical Corporation, Doha, Qatar.
Vice Dean for Medical Education, Weill Cornell Medical College in Qatar