Our college and Competence by Design

As I had mentioned in my first blog of 2018, Competence by Design (CBD) is a key topic on my mind as we move forward with the strategic priorities of our college.

One of the changes in the ongoing reform of medical education is a shift towards Competency-Based Medical Education (CBME). CBD is a multi-year transformational change initiative aimed at implementing a CBME approach to delivery of residency training and specialty practice in Canada, led by the Royal College of Physicians and Surgeons of Canada. The underlying rationale is that physicians will be better equipped to meet evolving societal needs and to provide better patient care. CBME is an outcomes-based approach to education delivery where learners must demonstrate that they have acquired all competencies required for unsupervised practice of medicine. It ensures that both learning and assessment are focused and individualized.

Our residency programs have been adopting CBME in a phased manner. Family Medicine has been reforming its residency program since 1998, with a focus on workplace-based assessment and curriculum reform through triple C competency-based curriculum: comprehensive care and education; continuity of care and education; and centered in Family Medicine. Specialty training has been based upon competency framework(s). However, the formalization of the CBD initiative by the Royal College of Physicians and Surgeons of Canada is relatively recent.

Although not a paradigm shift, CBD comes with its own language and vocabulary, such as: entrustable professional activities – a key task of a discipline in a clinical setting that can be delegated to a resident who has demonstrated sufficient competence; milestones – a marker of an individual’s ability along a developmental continuum; competency – observable ability that develops through stages of expertise from novice to mastery; and other terms describing stages of development. The key change with this approach is an emphasis on direct observation and feedback. The preceptor’s role shifts to coaching (assessment for learning) from the earlier position of judgment requiring pass/fail decisions (assessment of learning).

The PGME unit, under the leadership of Associate Dean Dr. Anurag Saxena, is leading the implementation of CBD at the CoM using three guiding principles: collaborative endeavor, distributed leadership and change tailored to developmental readiness. Organization-wide ownership, including by our learners, is at the heart of CBD. The individualized approach to implementation for each residency program requires coordination of efforts, consistent stakeholder engagement and appropriate resources.

Lessons from earlier and ongoing implementation of triple-C curriculum in Family Medicine are particularly informative and I am glad to see these are being applied, along with involvement of our provincial head of Family Medicine, Dr. Kathy Lawrence, in CBD implementation for specialty programs. Fluid coordination between PGME and Faculty Development, led by Dr. Cathy MacLean, also positively reflects how we leverage our strengths in a strategic manner to achieve our goals. Our provincial heads are crucial to success in this implementation and I know they are involved at the outset in CBD implementation in their departments.

Anesthesiology was the first program at our institution to go live with CBD, doing so in July 2017. Being first out of the gate, this program has been instrumental in clearing the path for others to follow. Emergency Medicine, Nephrology and Surgical Foundations are preparing for a July 2018 launch.

I am aware of the challenges inherent in balancing innovation and creativity with delivery of results in a timely manner, and I’m confident that our PGME unit and residency programs will make this transition successfully. CBD implementation in our college is a fine example of integrating academic and administrative leadership in instituting change across our programs, and CBME offers an opportunity to evolve through reflection on our own practices in teaching and learning.



One thought on “Our college and Competence by Design

  1. Well said. This is most significant change in residency training and assessment in 100 years. A true move from a time based to competency based assessment.

    There are also significant changes to how we view not only the training process but recognizing that the transition to practice has to be a managed actively as well – as this will be forming the last portion of the residency.

    Probably the most exciting aspect will be the merging of what is termed continuing medical education, development and competency in the practice years to better assist with the professional lifespan of the physician. Not the least, will be active recognition of the final years within clinical practice are as well a transition.

    All clinicians would benefit from accessing the high quality information available on the Royal College website. This is also a huge opportunity for staff to calibrate and improve their assessment skills for this transition.

    To a new era in post-graduate medical education !!!

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