By: Kim Lomis (@KimLomisMD)
Competency-based medical education (CBME) aims to reduce variability in the outcomes of training by acknowledging and accommodating varying pathways to competency development among learners. To accomplish this, core components must be present1: clearly defined desired competency outcomes, developmental sequencing of learning opportunities, tailored learning experiences, competency-focused instruction, and programmatic assessment to provide performance evidence that informs the entire process. Despite theoretical benefits, a commonly voiced concern about implementing CBME is a perception of resource intensity. A consideration of value is warranted.
Defining value is a matter of perspective. If we consider medical education’s purpose of generating the workforce needed to serve patients and populations, CBME offers enhanced standardization of the product of training and more deliberate assurance of each individual’s readiness for specific duties, while simultaneously elevating unique strengths of individuals. In the example of the transition from undergraduate to graduate medical education, receiving training programs could expect more consistency in performance among incoming interns, which in turn could reduce supervisory burdens, enhance patient outcomes and protect the well-being of trainees (based on greater confidence in one’s own competence). CBME also enables greater agility in meeting evolving competency demands based on societal needs over time and over one’s career, since the process of education is designed to be more flexible and precise.
From the perspective of the learner, value is manifest in multiple ways. Clarity of expectations and competency-focused instruction reduces the often-cryptic nature of educational experiences, from which learners lacking in social capital can be particularly disadvantaged. Frequent formative feedback informing personalized learning opportunities, ideally supported by performance analytics and coaching, fundamentally challenges the fallacy of perfection, acknowledges individualized strengths and opportunities for growth, and facilitates development. If executed well, CBME could promote greater equity in the assessment and advancement of learners given its criterion basis and the personalization of training pathways. Importantly, CBME empowers learners with greater agency in their own development, fostering master adaptive learners2 better positioned to grow throughout their careers.
Generating value requires investment. The value proposition canvas3 prompts consideration of what products and services a company must develop to meet the needs of the customer. Although I do not encourage a consumeristic view of medical education, for the purposes of this exercise I initially consider our trainees as the customer. The canvas starts with identifying what the customer is hoping to accomplish, their pain points, and gains they could anticipate with the implementation of CBME (Figure 1).
The canvas then prompts consideration of the features of a training program needed to support implementation of CBME. Programmatic assessment is critical, entailing time for observation and feedback, training of both assessors and learners in novel methods, informatics platforms to facilitate meaning-making of performance data, and support for new positions such as coaches and competency committees. Flexibility in the training process is needed to support personalized learning needs, sacrificing the perceived efficiency of scale of a mass production model. Importantly, investment in the culture of the organization to foster learning / working environments oriented around collective improvement and mastery is fundamental to fidelity in implementation of CBME4.
These features are resource intensive. Implementation with fidelity demands a reorientation that can seem overwhelming and is commonly cited as a severe limitation to the concept of CBME. Our community must continue to advocate for greater overall investment in medical education, as only an estimated 2% of total health care expenditures globally are devoted to training5. But we rarely discuss what current resource investments could be reduced or re-deployed to support CBME. Current curricular structures reflect an imbalance, favoring content delivery over assessment and feedback. In a previous role, I calculated that medical school investment in the pre-clerkship phase eclipsed that of the clerkship and final phases combined. And resources devoted to education are even scarcer as careers advance. Should we distribute existing resources differently?
Early phases of training are certainly worthy of resources and faculty play a critical role in helping learners grasp abundant challenging concepts. But the medical education community continues to invest redundantly across institutions in generating and delivering similar content, whereas most learners can readily find content, and indeed rely heavily on external sources. Exploding information has shifted the physician’s role from having the answers to asking the right questions. A persistent focus on content delivery has diminishing value, since it becomes increasingly impossible to cover all the content that will be needed6. Even in clinical phases of training, clinicians are pulled from care delivery to provide lectures, a costly endeavor that is often poorly sequenced or disrupted based on unpredictable schedules.
Many programs have redesigned interactions between learners and faculty to focus on application and observation to enhance learning relationships and facilitate deeper learning. This demands faculty time but generates assessment of competency development7. Early intervention to address developmental needs could reduce the significant scramble of resources devoted to learners discovered to be struggling upon transition to the next level of responsibility or nearing the end of a training program. Amplifying assessment and coaching in clinical phases could generate higher yield from the time faculty already invest, by being more precise in the alignment of teaching to need. Considering the entire continuum, meaningful assessments throughout the bulk of one’s career are exceedingly rare, with most resources devoted to delivery of content that may not be particularly relevant to an individual’s practice.
The prime perspective on value should be that of patients and populations. Lack of trainee preparedness for escalating responsibilities generates costs to patients and health systems that are often hidden in our discussions of educational investment. Health systems can be short-sighted in valuing clinical productivity over time devoted to educational roles or to physicians’ continuing development. Our medical education community must articulate the business case and long-term value of investment in education to support competency development and associated well-being across the continuum8.
Shifting resources from content delivery toward assessment of performance in authentic roles is needed to enhance value for learners, educators and patients. A systems perspective – applied at individual institutions and across institutions – is needed to reconsider how we invest precious educational resources across a physician’s career. Consideration of the current realities of practice, acknowledging the impact of exploding information and evolving technologies, may reveal creative opportunities to redesign for sustainable value.
About the author: Kimberly D. Lomis, MD is vice president for Undergraduate Medical Education innovations at the american medical association.
References:
1.Van Melle E, JR Frank, ES Holmboe, D Dagnone, D Stockley & J Sherbino; International Competency-based Medical Education Collaborators. A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs. Acad Med. 2019;94(7):1002-1009.
2. Cutrer WB, B Miller, MV Pusic, Mejicano GC Mangrulkar, S Rajesh, LD Gruppen, RE Hawkins, SE Skochelak & DE Moore. Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education. Acad Med. 2017; 92(1):70-75.
3. Osterwalder A, Y Pigneur, G Bernarda & A Smith. Value Proposition Design: How to Create Products and Services Customers Want. 2014. Hoboken, New Jersey: John Wiley and Sons, Inc.
4. Lomis KD, GC Mejicano, KJ Caverzagie, SU Monrad, MV Pusic & KE Hauer. The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education. Med Teach. 2021;43(sup2): S7-S16
5. Frenk J, L Chen, ZA Bhutta, J Cohen, N Crisp, T Evans, H Fineberg, P Garcia, Y Ke, P Kelley, B Kistnasamy, A Meleis, D Naylor, A Pablos-Mendez, S Reddy, S Scrimshaw, J Sepulveda, D Serwadda & H Zurayk. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923-58
6. Cutrer WB, WS Spickard, MM Triola, BL Allen, N Spell III, SK Herrine, JL Dalrymple, PN Gorman & KD Lomis. Exploiting the power of information in medical education. Med Teach. 2021; 43:sup2, S17-S24
7. Pettepher CC, KD Lomis, N Osheroff. From Theory to Practice: Utilizing Competency-based Milestones to Assess Professional Growth and Development in the Foundational Science Blocks of a Pre-Clerkship Medical School Curriculum. Med Sci Educ. 2016;26(3):491-497
8. Anderson, Knight, Rea, et. al. Educator well-being in academic medicine. American Medical Association. Accessed March 20, 2023: https://cloud.e.ama-assn.org/22-1665-Educator-Well-being-book
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