In Part I of our series on Competence by Design (CBD), the Royal Canada College of Physician’s and Surgeon’s version of competency-based medical education (CBME), we looked at some of the challenges in current medical education that CBD seeks to address.  While it may have been surprising to see such a long list of problems with what is often considered one of the best medical education curriculums in the world, it may be even more shocking to discover that that list was not exhaustive. 

The following is our second installment looking at the problems the current time-bound method of medical education presents, which CBD aims to remedy.

As time, not ability, is the current key judgment criteria, learners feel unprepared at stages

This is one of the key differences between CBME and current teaching methodologies, and one with radical implications.  The current time-focused education paradigm has many educational blind spots, one of which is preparation for taking on the responsibilities at new career stages, particularly when learners graduate to unsupervised care.

Dr. Jason Frank, ‎Director of Specialty Education, Strategy, and Standards, Royal College of Physicians and Surgeons of Canada, says in a Royal College webinar:  “There is evidence that learners are unprepared at some stages.  Think of a medical student going to residency, or a resident getting ready for practice.  There is evidence that learners feel unprepared at each level of change.  Another example is the movement from junior trainee to senior trainee.”

We still need to optimize training to minimize patient harm

In the same presentation, Dr. Frank says, “We have a culture that says we need to be far more attentive to keeping patients safe than our contemporary system because we’re much more aware now of the possibility of patient harm.  This leads to a situation in which we’re trying to optimize resident training.”

We’ve seen through projects like the Black Box that surgeons can feel overconfidence about the amount of errors they’re making in the operating room.  An interesting comparison the researcher behind the Black Box project, Dr. Grantcharov, makes is between pilots and surgeons.  Flyers don’t consider who the pilot is when choosing a flight, expecting all pilots to be of the same caliber.  Patients do consider the surgeon to be a significant variable, sensing material differences in skill and propensity to error may impact medical outcomes.

Through training, both involving skills training and culture, we can establish ways to ensure these errors get identified, rectified, and minimized.

Educational inefficiency due to faculty overload

We’ve spoken about the burden medical faculty feel and the difficulties that arise from it.  Unfortunately, it’s difficult to account for the differences in quality offered by faculty at different sites, due to differences in personality, workload, free time, and so on.  Program Directors may know which procedures are being performed, but have no insight into whether feedback was given or what particular weaknesses in any given resident must address.

There is little offered in terms of lifelong learning

No matter what field doctors enter into, the scope and practice of the field will change over time. Currently there’s no systematic way for them to maintain their competence in relation to evolving best practices.  Can CBD account for this?

Assessment should be part of the learning process

Dr. Frank says there’s a “[n]eed for assessment for learning instead of of learning.”  In other words, assessment should be transformed to be an opportunity to seek and give feedback, as opposed to an obstacle – consider exams – that learners need to overcome.

In the next part in our series, we’ll examine some of the solutions CBD offers to these challenges.