Thursday, February 14, 2013

Competency-Based Education Systems

I wish I could have been there, but I read the evaluations and it sounds like most of you enjoyed the topic and the exercises.  For many of you who were educated in a traditional norm-based, knowledge-centered educational systems, CBE may seem very different and perhaps an unnecessary change in focus.  For example you might ask "What is so wrong with knowing a lot".  The fathers  (and mothers) of CBE would answer that question..."Nothing, as long as you are able to use that knowledge to solve a problem, help a patient, communicate better, etc.  What do you think about the rise of CBE in medical and health science education?

14 comments:

R Prayson said...

The rise of CBE does provide a different focus in health science education than the traditional educational model I trained with. I feel a bit like we have jumped off a diving board without making sure the water is deep enough. There seems to be a widespread push toward this approach, which empirically seems to make more sense. However, the devil is in the details and there is a lot of detail that still needs to be worked out. We are still ruled by time-based constraints. So although we are aiming for a competency-based approach and we recognize that some take longer to achieve competency than others, “longer” is still restricted by conventional training time limits. It is generally not looked upon favorably if a resident needs an extra year or two of training because they are not yet competent. The determination of what defines competency is obviously subjective. Attempts at trying to precisely define this (which seems to be the recent trend) run the risk of actually minimizing things. Some trainees only feel the need to reach competency in the specifics defined by standards and nothing else. Assessing for competency also provides a challenge. In an environment where mentors are pressed for time, the formative assessment needed to make CBE work is time consuming and in many cases is a foreign concept (for those who trained in a traditional setting). Assessments need to be detailed enough to be useful for the learner and standardized enough to make determinations as to whether or not the learner has achieved competency.

Elias Traboulsi said...

I read with interest Dr. Prayson's comment. I agree that we are still learning how to assess and impart the competencies. I am actually amazed that generations of physicians have graduated under the "older" system (yours truly included) and have done so well. I can tell you that there are many (a lot of) components of the competent practice of medicine that graduates under the old system learned on their own after they finished their "training". Unfortunately, many go on struggling for a while before they achieve the "expert" level of competence. I believe that the new system has moved up the attaining of some of the competencies such as system-based practice or professionalism by bringing them up to the level of importance of other more traditionally taught and evaluated competencies such as medical knowledge or surgical skills. In this era of increasingly complex health care delivery and demanding societal expectations, the success of medical graduates really depends on their expertise in all competence areas. I agree with Dr. Prayson that the devil is in the detail. The approach has been one of emerging design with dicovery of the detail as we are applying the mandate. I sense that it is starting to work, but we have a long way to go.

Brian Johnson said...

I would absolutely agree that the devil is indeed in the details as Rich and Elias have said. The biggest issue I have seen with this push is the faculty development piece of the pie. I struggle to get my faculty interested in learning the competencies in there current form and dread the upcoming milestones which will only complicate matters. Tools that are simple enough to generate assessments by staff that are not trained in the details of the milestones, yet generate the information needed by program directors. Without these I feel we will continue to have great difficulty.

Zatarra said...


Wow! these are all great comments. I just have to agree with all that has been said so far. Although I personally think that the CBE seems to make more sense overall, it appears as it is missing significant elements in the design. Just as my colleagues have mentioned, the lack of enough assessing tools to monitor progress of the students abilities, insufficient trained teachers to be able to accomplish these monitoring tasks; and a big one would be "time" a commodity ever so scarce and expensive! How do we determine as "objectively" as possible if a student has grasped these abilities, knowledge, skills, attitudes and values? Even more so, how do we do it if you have a large group of students? I don't want to sound like a buzz killer, but I see many unresolved issues with this method. I don't think that the current banking method is perfect either, which I think emphasizes too heavily on memorization and not on integration and reasoning. As mentioned by others above, there seems to be a lot of work to do.
Miguel

Heidi Gdovin said...

Competency Based Education is a new concept for me as I have not been involved with curriculum development, formal teaching or student evaluation. I found the discussion of this newer format of learning and evaluation intriguing and I can see how this approach may be both exciting and challenging for those involved in the process. As the other posts have mentioned, there seem to be some aspects of this model that work well and other areas that need further development. I like the idea that learning is moving from knowledge acquisition to more of knowledge application. Although I may not be able to use or apply the framework of CBE in my roles today, it is a concept that I have been exposed to and may be able to use and apply in the future!

Brian Burkey said...

I agree with all the comments made so far. I am hopeful that competency-based education will raise the bar for our graduates, but I don't think it will reach its potential until we incorporate its concepts into all phases of curriculum development, assessments and teaching methods. Then we have to carry out the faculty development necessary to have all the teachers play an active part in the process. We are a long way from attaining that goal I think currently we are trying to paste the competency-based ideas on the traditional system and this is causing frustrations. As some of our teachers say, the current growth is evolutionary and we need a revolutionary process in order to transform medical education and gain the improvements we hope to achieve. However, we are the future and we can be transformative if we play an active role in our respective educational roles, and then recruit others to do the same.

Anonymous said...

Matt Celmar said...

CBME is an idea that I think has some real potential to revolutionize how we educate, assess, and practice. Coming from a constructivist education environment, many of the ideas associated with CBME (curriculum and assessment) are very familiar to me. It has a very holistic quality of how we educate medical professionals. The current problem with CBME is that it is trying to assimilate into a system that was never designed for it.
The culture and structure of the medical system is the byproduct of a norm-based, factual, educational model that has been in place. I agree with some others that there almost needs to be a revolution of sorts in order for CBME to matriculate through the medical institutions.
Possibly, as the younger generation who is more accepting of CBME and different ways to educate become the leaders in the field, we will see it become the predominant educational paradigm. As with most philosophies, there will be a pendulum effect. Norm-based and CBME are at opposite ends of the spectrum. As the pendulum swings back towards the center we will be left with a system that has elements of both but is different than that which we have today.

Anonymous said...

David Wheeler

Competency Based Medical Education, (CBME), is a paradigm wherein the curriculum is based on the competencies, demonstrated abilities and proven skill sets of the learner. In CBME there is a focus on educational outcomes and an emphasis on ability acquisition in a learner-centric context or framework. The curriculum is designed to promote both knowledge and ability acquisition on the part of the learner. I find this approach very interesting and think it fits the educational needs and expectations of the contemporary student population. The contemporary student population has been told since they were in pre-K. that they were special. Antiquated systems may not serve them. CBME may be just the thing for this generation of learners. The clinical application of didactic knowledge and physical skills requires a real-life demonstration of ability or competency. The emergence of simulation and case-based teaching are interesting in that they can easily be an essential component of a CBME program. Obviously, a demonstration of clinical knowledge and competence requires a great deal of standardization and validation. Additionally, one has to determine what is meant by competence. The determination of a standard of competence in any discipline requires validated and evidence-based assessment tools. I agree with my colleagues in that this form of learning is constructivits and could be transformative.

Maged Argalious said...

One of the steps in leading change (John Kotter's model) is getting buy in from all stakeholders.
I do not think that the ACGME has communicated clearly its vision for why competency based medical education will accomplish what traditional health care education systems failed to achieve. It may also be that we are spending less time on adopting and embracing those changes. I agree with Brian Burkey that most programs are trying to paste competency based outcomes onto the traditional education curricula. Multiple reasons exist for this, including the lack of knowledge in the true meaning of competency based curricula, the huge time committment required to generate de novo competency based curricula that addres each of the 6 ACGME competencies and the requirement for financial as well as time committment to execute the educational methods associated with comptency based curricula ( simulation, case discussions, debriefing sessions). I also wonder how receptive the respective specialty medical boards will be to these competency based outcomes. If residents achieve all the required competency based outcomes in a shorter time than what the traditional time based criteria dictate, will they be eligible for earlier board certification?

Anonymous said...

Kathy Baker

Competency Based Education, (CBE) seems to be an inevitable change and implementation in the medical and health professions. I think that due to changes occurring and the fact that people are scared of change, or at least weary of it, CBE will take a while to fully implement and show benefits. As so many are set in their ways with the education they have gone through, I think CBE will really show benefit and be accepted as it is implemented and newer generations come in and begin to go through the process. I agree with Matt in this regards. The idea of CBE is familiar to me in my current work environment, but foreign in regards to other work environments I have been apart of.

Karen George said...

Physician Assistants have closely mirrored the medical model for education and training. However, our profession's lifespan has not been as lengthy as that of physicians. The ability to adapt and think out of the box may come a bit easier for our newbie profession. I am uncertain to what level the PA programs are truly using the CBE model and it would be interesting to research this topic. The same constraints listed by Rich, et al, apply to us with the biggest being time and educating the educators in CBE. Most CBE is honed during the clinical rotations and these are diverse and coveted. I agree strongly with the possibility there has been a jumping the gun approach to instituting CBE. More educating the educators on this method and clearly establishing the competency criteria (big task) will help CBE become the established method of educating especially in the clinical years.

Shelley Frost said...

Shelley Frost: I agree with others that have commented on the faculty development necessity inherent in CBE. It takes more work to examine the learning experience through the lens of: competencies, practice abilities, milestones and outcomes. Identifying and targeting each competency really allows the learner to have a much more meaningful learning experience. I prefer more interactive styles of teaching and assessment methods. I like that the student has a responsibility to engage with and learn the material to ask how they are doing versus can they pass a test. We hope to create self-regulated learners that can recognize their own gaps and seek out the deficit knowledge or help in building the lacking skills.

Rachel Steines said...

The idea of transforming a system into a demonstration of mastery seems to make a great deal of sense. Required classroom time is always a drag, but mastering a competency is something we strive for based on human nature. Working on our skills until we are able to demonstrate their understanding and have the ability to apply them would ultimately make for better prepared individuals. The knowledge acquired from this type of education would be retained better than that of a traditional system. This topic was largely targeted to the medical school and residency programs during our meeting; however, I think this system should be implemented in undergraduate education and perhaps even high school education. I think teachers would have to be creative with teenagers if this program was used in high school, but I think it would be very beneficial for the students. I believe students would find this type of education motivating and engaging, and it would give students who struggle on a particular subject or just take longer to grasp a topic time to master the competency at their own pace. I think it might be hard for some students, high school students in particular, to figure out the balance between a comfortable and challenging pace. Teachers and guidance counselors would have to enforce work habits so this model was used appropriately. I believe this could be a revolutionary model for success in our country.

Anonymous said...

Felecia,

The seminar on Competency based training seemed very familiar to the style of training used to train Nurses. This type of training reminded me of the clinicals nurses have to complete before they can move on to the next phase. Nurses must be able to read about a process, watch demonstrations of the processes being taught and then demonstrate their ability to perform the processes. This form of training has also been used during my training as an educator and subject matter expert (SME) from a previous position. As a sme this training was termed process activated training (PAT’s). The process activated trainer would require the process activated learner to comprehend written material, then demonstrate working knowledge of the material. The learner would not be able to work in the field until all competencies were met. I believe the idea of CBET has been around for a while and is a good way of training individuals. With a set of competencies to be met it leaves little room for important processes to be left out. With each of these processes the burden of knowledge acquisition is placed on both the instructor and the learner. Each skill set begins with the instructor will….. and ends with, the learner will be able to……it is concluded with the evaluation and debriefing of each process. I feel this form of training if applied correctly, would greatly improved performance and patient outcomes.