Competency-Based Medical Education Takes Shape
—By Jane Sherwin, special to the Reporter
With new medical and scientific knowledge coming to light each day, medical educators realize that memorizing specific lists of facts and data is no longer the ideal way to learn. Not only might that information be outdated by the time graduation rolls around, but it also may not prepare tomorrow’s doctors to practice and learn in an ever-changing clinical environment.
Competency-based medical education may be the answer. It is a curricular concept designed to provide the skills physicians need, rather than solely a large, prefabricated collection of knowledge. A medical school or residency program using competency-based medical education defines a set of skills or competencies based on societal and patient needs, such as medical knowledge, patient care, or communications approaches, and then develops ways to teach that content across a range of courses and settings.
“Competency-based medical education focuses on what a physician should actually be able to do,” said Carol Aschenbrener, M.D., AAMC’s executive vice president and chief strategy officer.
The competency-based approach still includes scientific knowledge, but in the broader context of a physician’s tasks as a healer. A competency-based curriculum also seeks ways to achieve greater diversity among medical students, factoring in skills and backgrounds that could enable them to meet the needs of their communities.
Teaching methods for this approach tend to eschew larger lecture courses and intense examinations for more seminars, group discussions, active clinical learning experiences, and ongoing formative assessment including peer review. In addition to essential sciences, a competency-based curriculum may address topics in anthropology, sociology, or communications. Furthermore, whereas traditional medical education presumes that all students are ready to graduate once they have completed a set number of years of study and passed the required assessments, there is a growing interest in tailoring the length as well as the content of medical education to individual aptitudes. According to Aschenbrener, this dovetails well with competency-based education.
“People learn in different ways and at different speeds,” Aschenbrener said. “It’s important to take account of these differences in preparing students.”
Faculty engagement is, of course, central to any change in an approach to training. In the case of competency-based education, professors ultimately will need to learn how to integrate a variety of materials from several different fields—some of them quite possibly outside their area of expertise—into their own lesson plans. It also tends to call for more dialogue with students, and evaluation methods that may involve a range of techniques. Though it may require major adjustments, it may be an idea whose time has come.
“There are 40 years and more of recognition that long hours in classrooms followed by intensive written examinations and brief hands-on training were not meeting society’s need for skilled physicians with a full understanding of their patients’ needs,” said Aschenbrener. “As early as 1932, reports emerged saying that it is not enough to stuff students’ heads with information. They must be given greater responsibility for their own learning, and be trained on how to draw conclusions and assess a situation.”
Aschenbrener also points to shifts in education theory, including a growing awareness in the 1970s and 1980s, of the need for methods other than semester-by-semester absorption of material. At the same time, new tools appeared for assessment that could convert performance, rather than display of knowledge, into grades.
In addition, for many years there have been growing pressures for the medical profession to respond to society’s demands for better, safer health care. Jason Frank, M.D., M.A., associate director of the Office of Education for the Royal College of Physicians and Surgeons of Canada and director of education in the University of Ottawa’s department of emergency medicine, wrote in a 2010 article in the journal Medical Teacher that “medical educators are concerned to ensure that the 21st-century postgraduate medical education system is focused squarely on meeting societal needs. The challenge is to ensure that medical graduates demonstrate competence in all domains, and that these competencies are properly assessed.”
Medical school faculty have approached the transition to competency-based education in a number of ways. Dartmouth Medical School’s David Nierenberg, M.D., senior associate dean for medical education, described a gradual process of transition to a competency-based curriculum, based on years of faculty dialogue.
Paula Wales, Ed.D., interim associate dean for medical education and curricular affairs at Indiana University School of Medicine, also described a gradual process of engaging interested faculty in the competency-based approach, starting with exploration of the concept followed by the admission of the first competency-based class in 1999. At Case Western Reserve University’s school of medicine, Vice Dean for Education and Academic Affairs Daniel Ornt said that school leadership’s decision to launch an entirely new medical curriculum facilitated the transition to a competency-based approach.
The competency-based approach may, or may not, call for new technologies and expenses. Its most essential elements appear to involve curriculum planning, with the faculty and staff legwork and discussion and debate always part of the changes. Evaluations are likely to include the costs of “standardized patients,” individuals trained to simulate the symptoms of real patients—and to analyze students’ performance. Nierenberg argues that such expenses, like the purchase of simulation tools, are justified by their role in improving patient care and preventing harm.
Several other issues face medical schools and graduate medical education programs considering competency-based education. Thomas Pellegrino, M.D., associate dean for medical education at Eastern Virginia Medical School, said, “We are wrestling with it just like everyone else. The challenge is not so much accepting the concept, which we think is great, but figuring out how to make it work. Where do we teach? How do we evaluate performance? How do we remediate students who have not met requirements?”
How to define competencies, and how to assess performance are perhaps the two most significant concerns about competency-based medical education. Peter Katsufrakis, M.D., M.B.A., vice president for assessment programs of the National Board of Medical Examiners, said that it has been a slow process to achieve clarity around competencies, with “at least a decade of conversation” about the meaning of terms such as “professionalism.”
One response to defining competencies has been the concept of “entrustable professional activities,” designed to reflect the complex integration of skills needed in actual day-to-day practice. For example, an entrustable professional activity for a pediatric hospitalist may be to ‘‘serve as the primary admitting pediatrician for previously well children suffering from common acute problems,” as University of Maryland School of Medicine pediatrics professor Carol Carraccio, M.D., and her colleagues suggested in a 2002 article in Academic Medicine.
As to assessment tools, “we’ve been wrestling with this question for decades,” said M. Brownell Anderson, M.Ed., senior director for educational affairs at AAMC.
“The challenge is to measure the impact of training in terms of improved patient care, and to assess the extent to which a physician is a self-directed, reflective thinker,” Anderson said.
With respect to the future, competency-based medical education is emerging in many of the requirements now faced by graduating medical students, residents, and practicing physicians. For example, Step 2-CS of the United States Medical Licensing Examination involves interaction with 12 different standardized patients. And Katsufrakis points out that the licensing examination reflects the leadership of medical schools, including guidance on methods of evaluation.
Still, as Anderson observed, “adopting a competency-based model means different things to different people, and every medical school is unique.” Eastern Virginia’s Pellegrino said that AAMC meetings on competency-based medical education have been helpful, especially in learning about what other schools are doing.
“But,” Pellegrino said, “every school is a little different, and we have to decide ourselves how to make it real.”