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Competency Based Medical Education CSIM 2019
Ford Bursey MD FRCPC FACPProfessor of Medicine Memorial University
The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational
purposes, and should not replace other sources of information or your medical judgment.
Learning ObjectivesUnderstand the background behind CBME adoptionEmploy CBME concepts and techniques in the
education of traineesDistinguish feedback from coachingAppreciate the process of CBME as it moves into CPD
and assessment of competence in practice
Company/Organization Details
Advisory Board or equivalent
Speakers bureau member
Payment from a commercial organization. (including gifts or other consideration or ‘in kind’compensation)Grant(s) or an honorarium
Patent for a product referred to or marketed by a commercial organization.
Investments in a pharmaceutical organization, medical devices company or communications firm.
Participating or participated in a clinical trial
CSIM Annual Meeting 2019Conflict Disclosures
Definition: A Conflict of Interest may occur in situations where the personal and professional interests of individuals may have actual, potential or apparent influence over their judgment and actions.
Disclosures
Steering Committee Member of FMEC-PG
Steering Committee Member of CanMEDS 2015
CPD Educator for the RCPSC
Member of International Working Group on CBME
The International Conference on Residency Education | La conférence internationale sur la formation des résidents
Diagnosis: The Ballistic Model of Med Ed
Competence by Design
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Evidence suggests that where a physician trains determines the level of care that physician will provide throughout his/her career.
The International Conference on Residency Education | La conférence internationale sur la formation des résidents
Criticisms of Modern Med Ed:
Competence by Design
8
The International Conference on Residency Education | La conférence internationale sur la formation des résidents
The outcome of time-base models: Competence drops over time
10
Competence by Design
Klass Acad Med 2007Certification
Growth of Medical KnowledgeDoubles every 3
years
Up to 17% of highly quoted research is subsequently refuted
Holmboe, after Anders Ericsson: Used by Permission
The “Miracle” of Medical Education
Standardize outcome, individualize process
Integration of knowledge into roles
Habits of inquiry and improvement
Professional identity formation
CBME: Start with System Needs
16Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010
Undergraduate Postgraduate Professional Development
Lifelong Learning
MOC Educational Principles
• Need based
Personal
• Continuous improvement
Reflection• Scope of
practice
Choice
Learner-centered professional education
New MOC Program - Spring 2011 Only Three Streamlined Sections
Group learning activities
Self-learning activities
Practice assessment activities
What is the Evidence?
Studies of the Impact of Commercially Supported CME on Prescribing Practices
Studies of Physician Opinions about Bias in Commercially Supported CME
Studies of How to Measure Bias in Commercially Supported CME
Aldous HuxleyThere are things known and there
are things unknown, and in between are the doors of perception
Effectiveness of CME
Effectiveness of CME: Updated Synthesis of Systematic Reviews; R Cervero and J Gaines, July 2014Updated 2003 report (31 previous, 8 new)CME has a positive impact on physician
performance and patient health outcomes (more so on performance than patient outcomes)
Suggested it is best if interactive, uses more methods, involves multiple exposures, is longer, and is focused on outcomes that physicians consider important
Physician Self-Assessment
Physician Self-Assessment“Learners do not know what they don’t
know.” Systematic Review: Compared physicians’ self-rated
assessments with external observations Self-assessment accuracy is poor to limited Inaccuracy is independent of training level, specialty, domain or
manner of comparison Worst accuracy in self-assessment among physicians that were
least skilled and most confident
Davis D et al. JAMA 2006;296:9:1094-1102
Self-Assessment
Study Inclusion Criteria.
1. Compared physicians' self-rated assessments with external observations
2. Used quantifiable and replicable measures
3. Study population:> 50% practicing physicians, residents, or similar health professionals
4. Conducted in the United Kingdom, Canada, United States, Australia, or New Zealand.
Self-Assessment Areas of Self-Assessment
1. Teaching skills
2. Clinical or procedural skills
3. General medical knowledge
4. Language and cultural competence
5. Critical appraisal skills
Self-Assessment
External Assessments
1. Simulation
2. OSCE / Standardized patients
3. In-training examinations
4. Structured interviews
Self-Assessment
Results17 of 725 articles met inclusion criteria
20 comparisons between self and external measures
• 13 demonstrated little, no, or an inverserelationship
• 7 demonstrated a positive association
Self-Assessment in Practice
Key Messages‘Personal, unguided reflection’ or any global judgment of one’s ability in a particular domain is…
1.Poorly performed2.Unlikely to be enhanced through training or education!
3.Needs data and feedback to “inform self-evaluation”
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Role for Feedback…
Importance of feedbackImpact of workplace based assessment on doctor’s education and performance: a systematic review
Miller, BMJ 2012
“Performance changes were more likely to occur when feedback was credible and accurate or when coaching was provided to help subjects identify their strengths and weaknesses”
Acad Med. 2018 Jul;93(7):1055-1063. doi: 10.1097/ACM.0000000000002131.The R2C2 Model in Residency Education: How Does It Foster Coaching and Promote Feedback Use?Sargeant J1, Lockyer JM, Mann K, Armson H, Warren A, Zetkulic M, Soklaridis S, Könings KD, Ross K, Silver I, Holmboe E, Shearer C, Boudreau M.
relationship building, exploring reactions, exploring content, and coaching
Medical Education. 53(5):426–427, MAY 2019. DOI: 10.1111/medu.13833 Bringing meaning to coaching in medical education Ben Lovell
April 15-16, 2015 | Ottawa, Canada
The International Invitational Summit on Competency-based CPD
• 3 White Papers
• Rationale for a Change to Competency Based CPD
• Implications for Physicians, CPD Providers, and Health Care Institutions
• Assessment and Feedback for Continuing Competence and Enhanced Expertise in Practice
42CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
CBME PRINCIPLES FOR LEARNING• Education must be based on the health needs of the
population served• Primary focus of education and training should be on
desired outcomes for and demonstrated needs of learners
• Formation of a physician is a continuous progress of expertise throughout their practice life
• Opportunities for assessment and feedback should be available
43CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
KEY ELEMENTS OF A COMPETENCYBASED CME MODEL
• Revalidation, recertification, maintenance of competence, and maintenance of licensure systems are different BUThave COMMON GOALS of:
44CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
KEY ELEMENTS OF A COMPETENCYBASED CME MODEL
A. Ensuring physicians demonstrate a commitment to lifelong learning through:
• CPD activities • Use of multiple strategies and tools to assess
competence and performance and improve quality of care provided
B. Enabling physicians to progress through learning cycles based on:
• Practice scope• Performance data • Competency framework
45CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
SCOPE OF PRACTICE……AS TIMEGOES ON…..
CompetenciesATCertification
CompetenciesRevised SINCECertification
NEWCompetencies ADDED
ENHANCEDExpertise Competencies
TransitionOUT of Practice
Revised
Out of scope
CAG
IBS Practice AuditIBD Practice AuditCanadian GRS
Based on the UK tool and modified for use in Canada via input from both Academic and Community based centres
A web based tool that assesses quality from the domains of The clinicians perspective and The patients experience
Each domain has 6 different items that are evaluated
Canadian GI Global Rating Scale
The endoscopy Global Rating Scale-Canada: development and implementation of a quality improvement tool.MacIntosh D, Dubé C, Hollingworth R, Veldhuyzen van Zanten S, Daniels S, Ghattas G. Can J Gastroenterol. 2013 Feb;27(2):74-82
50CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
CANADIAN GI GLOBAL RATING SCALE
Clinical Quality Dimension• Appropriateness• Information/Consent• Comfort• Safety• Quality • Timely results
Quality of the Patient Experience• Equality• Timeliness• Choice• Privacy and Dignity• Aftercare• Ability to provide
Feedback to the Service
51CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
CANADIAN GI GLOBAL RATINGSCALE
• Levels and corresponding activity– D basic data gathering– C periodic review of
data – B response to
opportunities for improvement identified
– A response to changes is assessed
52CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
CANADIAN GI GLOBAL RATING SCALE
• This quality improvement tool is intended to be iterative and can be used to plan CBCPD for– An individual– A team of Physicians/Surgeons– An Interprofessional team– A Regional Health Authority– A Nation
Section 3: Practice Assessment Engaging in formal process that provides data
and feedback
Knowledge Assessment•Self assessment programs
3 credits per hour
No maximum
Performance Assessment•Simulation•Audit and feedback•Multisource feedback•Educational / administrativeassessment strategies
Ultimate Outcomes for Clinical Care & Education
A competent (at a minimum) practitioner aligned with:
CMS Triple Aim
Linking Clinical and Educational outcomes
National Health Service – UK. http://www.wipp.nhs.uk/tools_gpn/unit6_education.php
Competencies
Triple Aim
Questions/Discussion
Continuing Medical Education/Professional Development within a
Competency Based Medical Education
FrameworkJocelyn Lockyer
Ford BurseyDenyse Richardson
58CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
EXAMPLES OF INNOVATIONS IN
LEARNING
• Small groups that meet regularly
• Simulation• Activities that
inform self-assessment and self-directed learning activities
ASSESSMENT FOR LEARNING
• Audit and feedback
• Multisource feedback
• Direct observation in workplace
59CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
QUESTIONS FOR DISCUSSION (1)
• How do we help physicians identify their scope(s) of practice?
• How can we ensure that physicians can obtain data about population needs?– What sources are available?– How good are they?– What can be done to improve these data?
60CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
QUESTIONS FOR DISCUSSION (2)
• How can we approach the development of systems/initiatives to provide regular assessment and feedback to physicians?– What tools might be available?
61CONTINUING MEDICAL EDUCATION/PROFESSIONAL DEVELOPMENT WITHIN A COMPETENCY BASED MEDICAL EDUCATION FRAMEWORK | ICBME COLLABORATORS
QUESTIONS FOR DISCUSSION (3)
• What strategies are needed to ensure physicians can learn throughout their practice life ensuring they recognize the interrelationship between – CPD– Performance– Competency frameworks– Scope of practice
We believe that in the future, expertise rather than
experience will underlie competency-based
practice and…certification.
Aggarwal & Darzi, NEJM 2006
CBME is on the Horizon…