In Part I and Part II of our series on Competence by Design (CBD), the Royal Canada College of Physician’s and Surgeon’s take on competency-based medical education (CBME), we looked at some of the challenges in current medical education that CBD seeks to address.  Here in Part III, we’ll examine how the Royal College intends to address those challenges to make residents and physicians ready on Day One for the next phase off their careers.

We can break down the acquisition of any skill into five distinct stages:  Novice, Advanced Beginner, Competent, Proficient, Expert.

There is a push today to deliver medical education in a way that reflects the actual road to competence and proficiency, and ensures that the attention of both the faculty and learner is focused on achieving milestones along that road, and not on a simple test of the learning that routinely occurs after some fixed amount of time.   In fact, there’s a desire to move away from time as a major reference point – post graduate year, year of clerkship, and years of practice – and replace it with stage of skill acquisition.

The Royal College’s Competence by Design (CBD) addresses problems in current medical education and aims to be a hybrid between current teaching methods and competency based medical education (CBME), taking what works in today’s curriculum and combining with the best of CMBE.

A major goal of CBD is to make the transitions at each stage of medical education smoother, whether that transition be entry to residency, entry into practice, and professional development as field or scope of practice change.  The ultimate effect of these improvements, it is thought, is an aggregate improvement of patient care and experience.

Here’s how these stages break down in the Royal College’s Competency by Design framework:

Stage 1.  Transition to Discipline.

Consider this to be a learner’s introduction and orientation to a discipline and the Competency by Design approach to education in that discipline.  Each specialty and sub-specialty discipline will determine their own milestones.  This stage will include an assessment of the learner against the competency milestones to gauge the learner’s current abilities.  Once those are known, a program can be tailored according to learners’ individual strengths and needs.

Stage 2:  Foundations of Discipline.

As Dr. Jason Frank describes in his presentation on CBD, this stage “deals with broad-based fundamentals that prepare the trainee to move on to the core of discipline and have greater responsibility.”  The common skills that must be acquired before discipline-specific competencies will be addressed at this stage.

Stage 3.  Core of Discipline.

A critical point in this stage is the exam, which has been moved here from the very end of residency. As you can see, it now falls right in the middle of the stages of development.  This becomes a check on abilities of the learner instead of being the critical hurdle to overcome before certification for independent practice.

Stage 4:  Transition to Practice.

A simple exam to gauge whether a resident is ready for independent practice isn’t a robust way of determining competence.   Residents transitioning to practice often report feeling unready and under a tremendous stress moving to entirely unsupervised practice.  The transition to practice should be seamless in the minds of the learners; a transition in name and qualification only.

As Dr. Frank says, “Certification will occur in the new system when the residency committee signs off on a trainee as being ready for practice.  That can only occur after a period in Transition to Practice.”

Stage 5.  Life Long Learning and Continuing Professional Development.

This stage focuses on both maintenance of competence and enhanced expertise as the established scope of practice in a discipline changes.  There must be an organized way of continuing growth which ultimately translates into better patient care.

The key to understanding CPD’s transformational effect is not thinking that activities will change drastically but that “time will be treated as a resource, not the organizing framework.”