By: David R. Brown
Medical education has undergone significant changes over the past two centuries, evolving from the apprenticeship model to the Flexnerian model and finally to the Competency-Based Medical Education (CBME) framework. In this blog post, I will take a closer look at the evolution of medical education and the challenges and benefits of the CBME framework.
The Apprenticeship Model
In the apprenticeship model, which was prevalent from ancient times until the 19th century, medical students learned through direct observation and participation in patient care under the guidance of an experienced physician. This model was based on the premise that medical knowledge was best acquired through hands-on experience and direct observation of medical practices.
The Flexnerian Model
In the early 20th century, the Flexnerian revolution emphasized the importance of a strong scientific foundation and rigorous training in the basic sciences. This model was implemented through the establishment of medical schools that were affiliated with universities.
Critique of the Flexnerian Model
However, the Flexnerian model was criticized for its limited ability to prepare medical students for the complexities of real-world patient care. This critique led to a rethinking of medical education and the development of the CBME framework.
CBME: Contemporary Era of Medical Education
In the contemporary era of medical education, the focus is on competency-based approaches and the use of new and innovative educational technologies, such as simulation and standardized patients, to assess and develop the skills of medical students. There is also a heightened focus on patient-centered care and a greater recognition of the need for medical education to be responsive to the changing needs of society and healthcare.
Challenges in Implementing CBME
While CBME has its benefits, there are also challenges in implementing this framework. One of the main challenges is the lack of clear and consistent definitions of medical competencies, which makes it difficult to evaluate the effectiveness of CBME programs. There are also concerns about the psychometric reliability of entrustment decisions, as well as conflicting demands on faculty and limited evidence to support the effectiveness of CBME compared to traditional, time-based models of medical education.
Challenges with Entrustment
Challenges identified in the Core EPA Pilot entrustment process include ensuring sufficient assessment data, training faculty and clinical assessors in the new assessment framework, overcoming cultural resistance to change, addressing ethical considerations, and ensuring technological and logistical support. We entrust our learners when we meaningfully advance them in responsibility. We entrust our program directors and promotions committees to make these decisions. While data science has the potential to support these decisions, it is not yet advanced enough to take the place of direct experience.
Programmatic Assessment: Evaluating the Effectiveness of Medical Education
Programmatic assessment is a powerful tool for evaluating the effectiveness of medical education programs, as it provides a systematic and comprehensive approach to evaluating the outcomes of medical education. By collecting data on the performance of residents and fellows in real-world clinical settings, programmatic assessment can provide valuable insights into the strengths and weaknesses of a program and inform areas for improvement.
The Ultimate Goal of Medical Education
The ultimate goal of medical education is to produce physicians who demonstrate ability, reliability, compassion, discernment, and lifelong learning. These habits are the foundation of effective medical practice and cannot be reduced to a set of competencies or tasks. Medical educators should therefore focus on fostering these habits in medical trainees and continuously seek evidence to support their effectiveness in preparing competent and effective physicians.
Enhancing the Apprenticeship Model in the Contemporary Era
To reproduce the best of the apprenticeship model in the context of the complexities of the contemporary era of medicine, it is important to emphasize hands-on learning experiences, foster mentorship relationships, use technology to enhance learning, promote interdisciplinary collaboration, and foster a culture of lifelong learning. By taking these steps, medical education programs can provide medical trainees with the guidance, support, and resources they need to become competent and effective physicians. In order to reproduce the best of the apprenticeship model, which emphasized hands-on learning experiences, in the context of the complexities of contemporary medicine, it is important to maintain a strong focus on direct experience.
About the author: David R. Brown, MD PhD, is Professor and Chief of Family and Community Medicine at the Herbert Wertheim College of Medicine, Florida International University
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