This is Part 1 in our series on the Royal College of Physicians and Surgeons of Canada’s Competence by Design initiative. 

Canada’s Royal College of Physicians and Surgeons of Canada has launched Competence by Design (CBD) – a multi-year proposal to transition from the current time-based educational model in Canadian medical education to the outcome-based competency-based medical education model.

In the CBD plan, there is actually no intent to change the amount of time a learner spends in medical education.  Instead, at this point in the adoption of competency-based medical education, medical programs will “re-conceptualize time as a resource for acquiring competencies” instead of considering time to be the primary determinant of achievement.

This is a sensible middle ground between the traditional time-focused learning method and the radically different possibilities CBME offers if fully embraced.

The current model of education is based on the seemingly-intuitive notion that skills improve as more time is spent learning or practicing an activity.  While Canadian medical education has been praised around the world, there are significant problems that affect the competency of learners when they emerge from their residency programs, evidenced by the fact that residents, after a full four years of residency on top of a clerkship, still aren’t trusted to be competent without going through a hospital boot camp first.

In a Royal College webinar, Dr. Jason Frank, Director of Specialty Education, Strategy, and Standards, Royal College of Physicians and Surgeons of Canada, discussed some of these challenges.

They include:

Feelings of disempowerment

There is very little room for creativity or independent planning by learners entering residency. On the first day of residency, a student can predict his or her schedule, ward rotations, and skill blocks years out based on the current time-bound education model.    Instead of being proactive about identifying and filling the gaps that may be unique to that particular student, this model puts residents in a passive mode by default, simply receiving their lessons, Dr. Frank explains.

A burden placed on faculty

Faculty members are basically volunteers who take on a massive workload, complete an enormous amount of assessments, and devote precious time to resident supervision. All of this is done in addition to regular duties.   As students by default are passive in the learning process, the onus of getting the skills across to residents becomes an additional burden on the teachers whose bandwidth may be at capacity

‘Corruption’ of the exchange between teacher and learner

There is no systematic method of giving specific, actionable feedback to residents immediately after a procedure. Useful feedback that could ‘spur the learner on to the next stage of development’ is replaced by basically checking off boxes on a list.  There is little opportunity for a resident to dig into his or her weaknesses.

The unacceptability of failure 

This refers to the difficulty that faculty members experience giving ‘hard hitting’ negative feedback and the lack of best practices for students demonstrating sub-par skills to remedy their problems. As Dr. Jason Frank said in the webinar, “All of us probably have colleagues that we’ve talked to or we’ve experienced scenarios in which our colleague tells us verbally that somebody’s not doing so well, that they’re concerned about some behaviour that they saw in terms of the work of a trainee.  And then when that colleague is asked, ‘Did you document this? Did you put it on an assessment? Will you put it in writing?’, they may be reluctant to do so.  And there’s a number of reasons for that.  We need to build a system where that’s both useful and easy.”

Binary judgments

There is a lack of nuance when it comes to judgments about competence. A resident ends up as either competent or not.  This doesn’t represent 1) the scale of ability between novice and expert skills, and 2) the granularity of competence across a plethora of activities occurring during one procedure.

Absence of direct, uninterrupted observation

There is no system to capture what is occurring during the observation when a surgeon and resident are working together. Any feedback or observation is non-standardized and thus unpredictable and based on the personality of the supervisor.

‘High stakes national exams’

The opportunity cost in time and attention that residents spend preparing for their licensing exams takes away from what they could be giving to practical methods of improving competency, like seeking out feedback and performing activities that address their unique to their own weaknesses.

In our next post, we’ll go into further challenges that exist in the current method of medical education before moving on to some solutions proposed through competency by design.