In Finland, we use CanMEDS as the residency outcome competency framework. By definition, CanMEDS identifies and describes the abilities physicians require to effectively meet the health care need of people they serve. In Finland, CanMEDS was introduced ten years ago with a national Delphi panel, which translated and validated the competencies in Finnish. The final definitions were presented on a national website1. Everyone seems to know the CanMEDS Diagram,
We started CBME from scratch. Before the postgraduate education reform, we had a traditional time-bound education. Professors worked as program directors. Both residents and their supervisors were taken as workforce. The only assessment in this process was the written final examination. Very few clinical supervisors had any pedagogical education. Thus, assessments were rare, and residents frequently complained about the lack of feedback.
A new statute regulating postgraduate education took in effect in February 2020, and was the official starting point of CBME implementation in Finland. The number of EPAs increased rapidly, from 51 in 2020 to 404 in 2022. In the year 2021, there were 286 EPAs in 45/50 medical specialties, and in 2022 there were 404 EPAs in 47/50 specialties. Three specialties have chosen to have milestones only. A closer look at the CanMEDS competencies in those EPAs that we were able to retrieve2 from national webpage is as follows.
| CanMEDS | 2021 (N=118/286) | 2022 (N=284/404) |
| Medical Expert | 78.8% | 94.6% |
| Communicator | 84.7% | 90.3% |
| Collaborator | 71.2% | 80.6% |
| Leader | 51.7% | 56.7% |
| Health Advocacy | 26.3% | 35.3% |
| Scholar | 57.6% | 54.2% |
| Professional | 59.3% | 78.2% |
In 2021 Communicator was the most frequent competence assessed. In 2022 Medical Expertise was the most frequent, followed by communicator and collaborator. Health advocacy is the least frequently assessed competence. The results are slightly different in other countries. In Canada, Medical Expert is included in most EPAs3. However, the other six competencies are classified as intrinsic3, and they are not as frequently included in Canada as they are in Finland.
In Finland, the timing of the EPAs has not been defined yet, but it will be interesting to compare the results. In Canada3, Medical Expert is emphasized during the first three stages of training. Leader, Scholar, and Professional are concentrated in the final stages of training. Communicator starts high, Collaborator is consistent, and Health Advocate remains low3 as in our country.
Some surprises were revealed in our analysis. One specialty has included Scholar in all their EPAs but not Medical Expert. This was also missing from some very clinical EPAs. Nine specialties had included their own competencies, e.g., decision making, writing clinical guidelines, having holistic viewpoint. There were also other individual structures and definitions.
One might ask the reason for these misunderstandings. Perhaps we were too optimistic about everyone being familiar with the CanMEDS definitions. However, there might also be discrepancy between the official definitions and assessment at workplace. In their recent study, Andreou and co-workers4 used a Delphi panel asking if the competencies as such could be used as outcome measures and if they could be used as consistent outcome measures across different training settings. Their conclusion was that contextualization is needed before implementation.
Need for contextualization is also my personal experience, and we can take Communicator as an example. By definition, physicians form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care. Physicians should also communicate with all those involved in patient care. Effective communication varies depending on the context. Let us assume that we have an easy-going resident with great social skills. His patient collapses and he need to start with CPR-D. In that situation, very specific and clear closed-loop communication is needed. Despite his efforts, the patient does not survive, and he needs to go break bad news to the relatives anxiously waiting next door. Now a more sensitive, subtle approach will be needed.
We might also assume that specialties emphasize different competencies. In a recent survey (5), files of dismissed Dutch residents were studied. The most frequent causes of dismissal were insufficient performance of Medical Expert, Communicator, and Professionalism, but in most cases dismissed residents were unable to meet multiple CanMEDS competencies. For surgeons, inadequate Medical Expertise was the main reason for dismissal. In Internal medicine, the main causes were problems with Leadership and Medical Expertise. In diagnostic specialties, it was Scholar. In Psychiatry the problems were with the competencies Communicator and Professional.
In the future, the Finnish EPAs will be fine-tuned after feedback from residents and their supervisors. Our experience is that one should never take anything for granted. The definitions need to be explicit for everyone before they can be contextualized. I am looking forward to the evolution of our EPAs in the future!
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.
References:
1. CanMEDS Competencies in Finnish Kompetenssit.pdf (duodecim.fi)
2. Niemi-Murola L, A Toivonen, M Ryytty, A Helin-Salmivaara. EPAs in Finland EL322_91.pdf (sely.fi)
3. LoGiudice AB et al. Intrinsic or invisible? An audit of CanMEDS roles in entrustable professional activities. Acad Med 2022;97:1213–18.
4. Andreou V et al. Fitness-for-purpose of the CanMEDS competencies for workplace-based assessment in General Practitioner’s Training: a Delphi study. BMC Med Educ. 2023: 204
5. Godschalx-Dekker J et al. Do deficiencies in CanMEDS competencies of dismissed residents differ according to specialty? Medical Teacher in press.