On October 4 – 5, 2013, the American Medical Association hosted the “Accelerating Change in Medical Education Conference” in Chicago, IL., bringing together leaders in the realm of medical education for discussions aimed at “closing the gap between current physician training and the needs of our evolving health care system.”
The current Flexnerian model for medical education consists of two years of basic sciences followed by two years of clinical rotations. However, this older model is changing towards competency-based criteria in an effort to incorporate earlier clinical exposure and allow students to learn at different paces. At the conference, a question on many minds was: “What is the role of competency-based medical education (CBME) and how will it impact the medical school experience?”
There are many positives for a shift to this type of learning. CBME emphasizes the importance of knowledge application instead of knowledge acquisition. Learning tomes of textbook material has limited relevance in the hospital and clinic. Any physician would have to read 150 journals a month or 7,700 articles a year to stay informed. Instead, applying textbook knowledge to clinical situations provides practical value to the student and better prepares them for future clinical situations.
In addition, students learn differently. Since medical students do not necessarily learn in the same way or at the same pace, why should they all be taught in the same way? With competency-based medicine, students can progress through the material at their own pace, providing they show competency in a skill set. This self-pacing concept is not new but has been gaining appeal over the past decade. Competency-based medicine has the potential to allow students to finish medical school sooner and at different points from their classmates.
With changes in medical practice, there is a shift to focus on outcomes as measures of performance, states AMA representative Dr. Richard Hawkins. Reaching specific levels of competency would be assessed through frequent performance evaluations during the learning process. By introducing evaluations from the first year of training, one gets used to feedback learning from an early point. Evaluations can help promote self-directed learning and provide explicit goals for self-assessment. The benefits of this system are that it can provide better and more constructive feedback. From the perspective of the educator, this system also helps facilitates curricular development.
Although necessary in competency-based medical education, evaluations present a problem for students and teachers alike. It is often difficult for individuals to provide their colleagues with poor evaluations. Professors who work closely with a resident would find it difficult to give him or her a failing evaluation. There is a stigma against poor evaluations, when “poor” is seen as “incompetent.”
Other disadvantages of switching curriculums become apparent upon further consideration. From a practical standpoint, the costs for administering a new system will be staggering. Dr. Kenneth Simons from the Medical College of Wisconsin states that there would be the “fear we are spending more time admin rather than ensuring quality of programs.” In addition to these costs at individual universities, one must consider the overall cost on a national level. A large amount of money would be spent developing individual curricula if there is no collaboration.
CBME would make it difficult to standardize competencies among universities on a national level. With individual medical programs seeking to serve their populations best, various schools would have different definitions of competency, and irregularities across the board would be detrimental to students as they apply for residency programs in various states. With the introduction of education technology, an increasing number of schools are introducing simulation- and computer-based interactive assessments during the first two years of medical school to possibly standardize certain competencies. However, technology is not a substitute for clinical experience. No simulation can duplicate a real clinical scenario, and clinical exposure is a valuable experience. Dr. George E. Thibault, President of the Josiah Macy Jr. Foundation, asserted that, “Technology will and should never replace face to face encounters.” However, he added, they can supplement the curriculum if appropriately used.
In addition to the difficulties inherent in implementing competency-based curricula, one must also consider how this affects the starting point of a residency. Traditionally, there is one entry point for new residents every year, following graduation. However, if competency-based medicine allows students to graduate sooner and at different intervals, there need to be residencies with additional entry points to accommodate these students.
CBME has been discussed for 50 years and many of these questions must be answered as it is slowly being implemented into medical education. For more information on current initiatives, please look into the Milestones Project, ACGME, and CanMEDS.