The ICRE congress 2019 in Ottawa was a wonderful experience for me. I learned so much, met many distinguished experts and had new perspectives for my work as a national CBME facilitator. After the congress, I returned home with stars in my eyes. I had become aware of our goal, which seemed so clear and easy to reach. At home, the reality struck. For implementation we need much more than the use of Google translator. In theory, practice will be easy – and in practice it is not.
When I returned from Canada, I made an inventory about what we had and what will be needed to reach the goal, a competency-based postgraduate medical education system. We have some factors facilitating the reform, e.g., active residents and some specialties had logbooks indicating that they documented the progress of their residents. We have also some factors which will present challenges to overcome. We had a traditional, time-based postgraduate education system and the only formal assessment has been a written final examination. The Five Core Components model presented by van Melle et al (1) was the greatest innovation I learned at the congress.
The first component, construction of a core competency framework was a relatively easy task. In Finland, we are members of the European Union of Medical Specialties/Union Européenne des Medecins Spécialistes (UEMS) and most specialties had based their curriculum to the UEMS recommendations. However, there are five medical schools, and each specialty has five professors as program leaders defining the contents of the curriculum. Each university had some special features which were important for the professors and at first, I was very sceptical. The UEMS served as a valuable reference and the national curriculum was easily constructed.
The second component, the progressive sequencing of competencies, was more challenging. In our country postgraduate education is given by the university and it takes place in healthcare system. Residents used to work six months in one ward, then three months in another and learned by osmosis. Many consultants, like myself, have traumatic memories from our days as residents, and it was relatively easy to justify the need for this component. When my colleagues learned about the EPA’s, they immediately started writing the first ones and I was pleased.
The third component, learning experiences tailored to competencies in CBME, was more challenging. In Finland, postgraduate education is given by the university, and professor has been the program leader without any staff. Education takes place in the healthcare system in which residents, their supervisors and preceptors are taken as workforce. Every specialty has some dull routine work which must be done but which does not facilitate learning of any new knowledge, skill, or ability. In the old days, residents were allocated for these tasks and consultants had the more interesting ones.
There are conservative, operative, and diagnostic specialties, each with their educational traditions. There are specialties with hundreds of residents and specialties with less than five residents. The national CBME facilitator constructs the main structure, but the 50 medical specialties are autonomous. One size does not fit all! Implementation of the reform we needed someone to coordinate residents’ work at the wards. In the University of Tampere, my colleague Johanna Rellman had introduced Academic Advisors (2) in Autumn 2018. Now we have Academic Advisors in all university hospitals and even in some secondary hospitals. They started by clarifying and constructing the structure of postgraduate education. They have affiliation both to the university and the healthcare system and as such, they are the true pioneers of the implementation process.
The fourth component, teaching tailored to competencies, will be taken care of the Academic Advisors, too. At present, most specialties have at least one EPA, and they have started the implementation process.
The fifth component, programmatic assessment, is closely linked to the fourth one. Introduction of formative assessment presents a great reform in our country. Until now, we have had a very traditional master-apprentice system and our residents have vigorously protested the lack of formative feedback. Fortunately, our electronic assessment system ELSA will be launched in June 2022. ELSA is a residency management system, and assessment issues are only part of it. The professor will be able to follow the progress of the residents – and lack of documentation will also be illustrated.
It would be wonderful if we could start implementation by translating all the great educational innovations. The fact is, that we must start from scratch. We have three drivers facilitating the implementation of CBME in Finland. The first one is our active residents who demand coaching and formative feedback. The second driver is the group of Academic Advisors who will implement the reform at the clinics and the third will be the electronic assessment system which makes the reform visible. Thus, we have started the reform both from the top and at the grassroot level hoping to reach the great majority of Finnish physicians.
About the author: Leila Niemi-Murola, MD, PHD, MME, AFAMEE works as national facilitator in CBME in Finland. She also works as a part-time consultant anaesthesiologist in the Helsinki University HospitaL and is a member of the Teacher’s Academy of the University of Helsinki.
1. van Melle E, Frank JR, Holmboe ES et al. A core components framework for evaluating implementation of competency-based medical education programs. Acad Med 2019; 94: 1002 – 09.
2. Rich JV, Young SF, Donnelly C et al. Competency-based education calls for programmatic assessment: But what does this look like in practice? J Eval Clin Pract 2019; 1-9.
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