1. CBME – AMEE 2013 IMELF 2013 1 of these is not like the other 2… Which one ? Why ?

2. Competency-Based Medical Education IMELF 2013 Linda Snell McGill University and RCPSC Nick Glasgow, Australia National Medical University Markku Nousiainen, University of Toronto

3. CBME – AMEE 2013 IMELF 2013 What do you think about CBME? A.It’s the future, but I don’t know how to start to implement it B.I am doing it, but there are many challenges in putting it into effect C.I am considering a CBME approach and have ideas but I don’t know how to make it work D.I am still not sure what it is E.It’s a fad that will go away. I am not going to change what I do now.

4. CBME – AMEE 2013 IMELF 2013 In this plenary … Why change? CBME – what is it? Implications – policy, systems Practical applications – design, delivery Outcomes

5. Competency-Based Medical Education: Opportunity or Threat? Some slides adapted from Jason Frank

6. CBME – AMEE 2013 IMELF 2013 CBME - Key Messages Competencies, and competency frameworks, form the basis of training for medical learners. Key principles of CBME: Focuses on outcomes Emphasizes abilities De-emphasizes time as an outcome Promotes learner-centeredness Challenges and concerns can be addressed. There is a spectrum of approaches for CBME design

7. CBME – AMEE 2013 IMELF 2013 What we will be talking about 1.Why change? Challenges facing medical education. 2.What is competency-based medical education? 3.Key principles of design

8. CBME – AMEE 2013 IMELF 2013 Time-based Achievement Achievement Which one is not like the others

9. CBME – AMEE 2013 IMELF 2013 Sara: halfway through PGY1 year. Completed rotations in medicine, emergency medicine, outpatient clinics, and geriatrics. Evaluations > “satisfactory”. Comfortable talking to patients; a good team member. She feels uncertain about her ability to fully assess new patients & develop a plan for management. Little opportunity to perform basic procedures.

10. CBME – AMEE 2013 IMELF 2013 Unsure of the level at which she should be performing now Does not know what standards she is expected to meet. Sara: halfway through PGY1 year.

11. CBME – AMEE 2013 IMELF 2013 What we will be talking about 1.Why change? Challenges facing medical education. 2.What is competency-based medical education? 3.Key principles of design

12. CBME – AMEE 2013 IMELF 2013

13. CBME – AMEE 2013 IMELF 2013 Challenges in Today’s Medicine Quality care – patient safety Explosion of medical knowledge, information management Maintaining competence New technologies Scant resources Workload Teamwork, new roles Globalization Societal responsibility

14. CBME – AMEE 2013 IMELF 2013 Challenges: The Public Wants … Access to safe, high quality care Compassion Communication skills Clear information Professional and ethical care Competence Consumerism

15. CBME – AMEE 2013 IMELF 2013 Criticisms of Medical Education Inefficient – too long, not focused on needs ‘Service’ vs. ‘education’ Heterogeneity of experiences Dehumanizing Biomedical / disease orientation Knowledge -> information management Generalist (core for all?) vs. specialist May not fully prepare for practice Not meeting society’s needs

16. CBME – AMEE 2013 IMELF 2013 Diagnosis? The “Ballistic Model” of Medical Education

17. CBME – AMEE 2013 IMELF 2013 Diagnosis? Is there a better way to ensure competence than just time spent? The “Tea Bag Model” of Medical Education

18. CBME – AMEE 2013 IMELF 2013 Unsure of the level at which she should be performing now Does not know what standards she is expected to meet. Sara: halfway through PGY1 year. How can we ensure our graduates are competent in all needed domains…?

19. CBME – AMEE 2013 IMELF 2013 We have a responsibility to society to produce practitioners for the future. Our current medical education approaches have not kept up with today’s challenges in medicine. Medical education is starting to change to address this.

20. CBME – AMEE 2013 IMELF 2013 CBME is on the Horizon We believe that in the future, expertise rather than experience will underlie competency-based practice and…certification. Aggarwal & Darzi, NEJM 2006

21. CBME – AMEE 2013 IMELF 2013 What we will be talking about 1.Why change? Challenges facing medical education. 2.What is competency-based medical education? 3.Key principles of design

22. CBME – AMEE 2013 IMELF 2013 Definition: Competence An array of abilities (KSA) across multiple domains / aspects of performance in a context. Require descriptive qualifiers to define the relevant abilities, context, and stage of training. Multidimensional. Dynamic: changes with time, experience, setting. Frank, Snell et al. Med Teacher 2010 “The habitual & judicious use of communication, knowledge, technical skill, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and the community being served” Epstein Epstein. JAMA 2002

23. CBME – AMEE 2013 IMELF 2013 Definitions An observable ability integrating multiple components: skills, values, knowledge, & attitudes. Since competencies are observable, they can be measured & assessed to ensure their acquisition. Competencies can be assembled like building blocks for progressive development. Possessing the minimum required abilities in all domains in a certain context at a defined stage of medical education or practice. Frank, Snell et al. Med Teacher 2010 Competent Competency

24. CBME – AMEE 2013 IMELF 2013 CBME - Competency-Based Medical Education …an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities, and organized around competencies derived from an analysis of societal and patient needs. 1 …an outcomes based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies. 2 1.Frank et al, Med Teacher 2010 2.Frank, Snell et al, Med Teacher 2010

25. CBME – AMEE 2013 IMELF 2013 Competencies seem to be everywhere in medical education these days…

26. CBME – AMEE 2013 IMELF 2013 ‘One World’… Core Competencies CanMEDS Australia - CanMEDS CanMEDS Holland ACGME UK Good Doctor Japan Competencies Saudi CanMEDS CanMEDS Chile

27. CBME – AMEE 2013 IMELF 2013 Outcomes-based Education “Begin with the end in mind…” “What are the abilities needed by the graduate…?” Societal Needs Work backwards

28. CBME – AMEE 2013 IMELF 2013 What we will be talking about 1.Why change? Challenges facing medical education. 2.What is competency-based medical education? 3.Key principles of design

29. CBME – AMEE 2013 IMELF 2013 Key Principles of CBME a)Focuses on outcomes b)Emphasizes abilities c)De-emphasizes time as an outcome d)Promotes learner-centeredness

30. CBME – AMEE 2013 IMELF 2013 Key Principles of CBME a)Focuses on outcomes b)Emphasizes abilities c)De-emphasizes time as an outcome d)Promotes learner-centeredness

31. CBME – AMEE 2013 IMELF 2013 Emphasize outcome over educational process Graduates must be competent in ALL domains Transparent to learners, teachers & public Standards criterion-based Must prepare learner for practice

32. CBME – AMEE 2013 IMELF 2013 Key Principles of CBME a)Focuses on outcomes b)Emphasizes abilities c)De-emphasizes time as an outcome d)Promotes learner-centeredness

33. CBME – AMEE 2013 IMELF 2013 “What are the abilities needed of graduates?”

34. CBME – AMEE 2013 IMELF 2013 Competency-based Curricula Emphasis on skills, attitudes … and their synthesis into observable competencies. A hierarchy of competencies replaces educational objectives as the organizing framework. Implies new teaching and assessment methods, and new ways of designing curricula

35. CBME – AMEE 2013 IMELF 2013 Planning CBME 1.Practice analysis – identify needs of graduates 2.Explicitly defined competencies & components 3.Milestones of achievement along path 4.Select educational activities, experiences, and instructional methods. 5.Select assessment tools to measure progress along the milestones 6.Program evaluation

36. CBME – AMEE 2013 IMELF 2013 Progression of competence For each aspect or domain of competence, the spectrum of ability from novice to mastery. The goal of medical education is to facilitate the development of a physician to the level of ability required for optimal practice in each domain. At any given point in time, and in a given context, an individual physician will reflect greater or lesser ability in each domain. Frank, Snell et al. Med Teacher 2010

37. CBME – AMEE 2013 IMELF 2013 Key Principles of CBME a)Focuses on outcomes b)Emphasizes abilities c)De-emphasizes time as an outcome d)Promotes learner-centeredness

38. CBME – AMEE 2013 IMELF 2013 Time is a resource. Learners progress at different rates, and may achieve competencies faster or slower than a peer. Emphasis should be placed on the progression of abilities and measures of performance. Greater flexibility may make some curricula more efficient and engaging.

39. CBME – AMEE 2013 IMELF 2013 Key Principles of CBME a)Focuses on outcomes b)Emphasizes abilities c)De-emphasizes time as an outcome d)Promotes learner-centeredness

40. CBME – AMEE 2013 IMELF 2013 A curriculum of competencies provides clear goals for learners. A roadmap of milestones provides a transparent path to achieve competencies. An individual learner can adjust their own learning using the milestones.

41. CBME – AMEE 2013 IMELF 2013 Hybrid model of CBME A focus on curricular outcomes An emphasis on abilities (competencies as the organizing principle of curricula) Logical progression A de-emphasis of time-based training Greater accountability, flexibility The promotion of learner-centeredness Standards visible Social accountability, relevance

42. CBME – AMEE 2013 IMELF 2013 Perils of CBME: Reductio ad absurdum Tyranny of utility Migration to the minimum (vs. excellence) Change takes energy New education approaches needed System impact

43. CBME – AMEE 2013 IMELF 2013 Examples Brown University 1980s EFPO 1990s CanMEDS Netherlands ACGME & American Boards Australia psychiatry Australia pre-grad University Toronto Orthopedics Texas …

44. CBME – AMEE 2013 IMELF 2013 Promise of CBME: Flexibility for individuals Logical progression Efficiency Transparent standards Relevance ensured Less time-oriented … ? Shorter for some Public accountability (needs based)

45. CBME – AMEE 2013 IMELF 2013 1.Why change? Challenges facing medical education. 2.What is competency-based medical education? 3.Key principles of design What we have talked about

46. CBME – AMEE 2013 IMELF 2013 Medical Education at a Crossroads

47. Competencies, Ballistics, Tea-Bags, and The End of Time?

48. CBME – AMEE 2013 IMELF 2013 CBME - Key Messages Competencies, and competency frameworks, form the basis of training for medical learners. Key principles of CBME: a)Focuses on outcomes b)Emphasizes abilities c)De-emphasizes time as an outcome d)Promotes learner-centeredness Challenges and concerns can be addressed. There is a spectrum of approaches for CBME design

49. CBME – AMEE 2013 IMELF 2013 What do you think about CBME? A.It’s the future, but I don’t know how to start to implement it B.I am doing it, but there are many challenges in putting it into effect C.I am considering a CBME approach and have ideas but I don’t know how to make it work D.I am still not sure what it is E.It’s a fad that will go away. I am not going to change what I do now.

50. CBME – AMEE 2013 IMELF 2013 Questions? Discussion points?

51. CBME – AMEE 2013 IMELF 2013 Design of medical education curricula CharacteristicTime-dependent Hybrid: Competency-based, Timed Rotations Time-free Organizing Structure Time spent on rotations Progression of competenceProgression of Competency Degree of StructureRotations Structured flexible curriculum; rotations as only one learning method Structured, learner-centred curriculum; time- independent; rotations secondary to learning Role of Timed Rotations Unit of curriculum Resource for acquiring competencies Irrelevant Role of In-training assessment “Pass rotations” Document progression & milestone achievement Role of summative assessment Infer readiness for exam Ensure achievement of competencies Key assessment tools ITER, oral exam Portfolio; many othersPortfolio; others prn Program focusProcesses for rotations Acquisition of competency outcomes via rotations and other activities Acquisition of competency outcomes Teacher rolesSupervision, teaching Supervision, teaching, direct observation Learner rolesService on rotations; academic contribution; study for exam Ownership of learning; plot course for progression of competence through rotations Ownership of learning; plot course for progression of competence through activities Snell et al CBME RCPSC White paper 2011

52. CBME – AMEE 2013 IMELF 2013 The spectrum of design approaches for residency curricula CharacteristicTime-dependent Hybrid: Competency- based, Timed Rotations Time-free Organizing StructureTime spent on rotationsProgression of competenceProgression of Competency Degree of StructureRotations Structured flexible curriculum; rotations as only one learning method Structured, learner- centred curriculum; time- independent; rotations secondary to learning Role of Timed Rotations Unit of curriculum Resource for acquiring competencies Irrelevant Role of In-training assessment “Pass rotations” Document progression & milestone achievement Role of summative assessment Infer readiness for exam Ensure achievement of competencies Key assessment toolsITER, oral examPortfolio; many othersPortfolio; others Program focusProcesses for rotations Acquisition of competency outcomes via rotations and other activities Acquisition of competency outcomes Teacher rolesSupervision, teaching Supervision, teaching, direct observation Learner rolesService on rotations; academic contribution; study for exam Ownership of learning; plot course for progression of competence through rotations Ownership of learning; plot course for progression of competence through activities

53. CBME – AMEE 2013 IMELF 2013 The spectrum of design approaches for residency curricula CharacteristicTime-dependent Hybrid: Competency- based, Timed Rotations Time-free Organizing StructureTime spent on rotationsProgression of competenceProgression of Competency Degree of StructureRotations & AHD Structured flexible curriculum; rotations as only one learning method Structured, learner- centred curriculum; time- independent; rotations secondary to learning Role of Timed Rotations Unit of curriculum Resource for acquiring competencies Irrelevant Role of In-training assessment “Pass rotations” Document progression & milestone achievement Role of summative assessment Infer readiness for exam Ensure achievement of competencies Key assessment toolsITER, oral examPortfolio; many othersPortfolio; others Program focusProcesses for rotations Acquisition of competency outcomes via rotations and other activities Acquisition of competency outcomes Teacher rolesSupervision, teaching Supervision, teaching, direct observation Learner rolesService on rotations; academic contribution; study for exam Ownership of learning; plot course for progression of competence through rotations Ownership of learning; plot course for progression of competence through activities