By: Daniel Nel (@danielnel87)
One of the most tangible ways that the introduction of CBME becomes apparent, is through a change in assessment practices. In South Africa, postgraduate specialist training occurs in academic hospitals affiliated with one of the country’s ten university medical schools. Traditionally, the evaluation and certification of trainees have been overseen by the Colleges of Medicine of South Africa (CMSA), an external regulatory body. In recent years, the CMSA and the South African Committee of Medical Deans, which represents the university training institutions, have collaborated to introduce Workplace-Based Assessment (WBA) as a measure of postgraduate trainee competence.
The process began with a series of national roadshows aimed at introducing new concepts and terminologies. Subsequently, face-to-face workshops were conducted at each university in the country. These workshops aimed to enhance capacity and identify leaders capable of launching pilot projects in various disciplines nationwide. An example of such an initiative was undertaken by the Division of General Surgery at the University of Cape Town. In October 2022, we embarked on an endeavor to determine the feasibility, acceptability, and appropriateness of implementing WBA within our specific context. However, introducing a substantial concept like WBA into an environment that had not previously encountered it, posed a significant systemic change.
Introducing novel initiatives into medical education systems is nothing new. One of the earliest AMEE guides (#10), authored by Gail and Grant, discusses the management of change in a medical context. John Kotter’s eight-step model, originally described in a business setting, is among the most well-known frameworks for change management, including in the medical field. His model offers practical steps crucial for achieving institutional change. Yet, knowing what actions to take differs from comprehending what is actually occurring. Change is often thought of as stepping through a doorway from one state into another. However, the change process is far more intricate and understanding this is pivotal when introducing substantial change like WBA into a system. Models of change, such as those described by William Bridges and Virginia Satir, posit that when an external element or change is introduced, a decline in performance can be anticipated as the system adapts. This decline has variously been termed the chaos phase, the wilderness, or the emptying phase. Recognizing this predictable dip after introducing a change is valuable in understanding the initial challenges. Change leaders, the individuals endeavoring to implement WBA, have a key role in minimizing the duration and impact of this phase.
It’s important to realize that change is not merely about organizational factors but also personal or inner transformation. In fact, organizational change is only the tip of the iceberg, with personal change being the mountain of ice below the surface. Another compelling way to explain this, and to guide the management of intrinsic or personal change, is Chip and Dan Heath’s concept of the elephant, rider and path. The rider represents the rational mind, the elephant embodies the powerful emotional mind, and the path signifies the environment. When we initially introduced WBA in our team, we devoted substantial attention to both the path and the rider. Clearing the path entailed creating a robust digital platform, streamlining the observation process to minimize disruption to clinical workflow, providing easy access through a smartphone app, and sending reminders to supervisors for assessment requests. To motivate the rider, we conducted multiple sessions involving faculty and trainee development. These sessions aimed to communicate the vision, outline the necessity of WBA, and underscore its integration as a component of CBME.
Nevertheless, after 6-9 months, it became evident that we still faced incomplete buy-in and participation. Despite our efforts to describe the importance of WBA and simplify the process, some individuals remained unconvinced. We had focused on the rider and cleared the path, but some elephants were reluctant to move! Recognizing that we had not tapped into intrinsic motivation, we convened a stakeholder meeting to brainstorm strategies to motivate both trainees and supervisors. Ideas included introducing a prize for the trainee who gets the most assessments per year, accompanied by funding to attend a conference. A similar award and prize was introduced for the most engaged supervisor and units. Consequences for poor participation were introduced, including delays in progression for trainees and, for consultants, accountability at their annual review with the HoD. We also added numbers of assessments done by individual supervisors and different units to the overall WBA dashboard, to take advantage of competitive natures and the intrinsic desire for affiliation. Although we have not achieved universal buy-in, critical mass has been achieved to move beyond the chaos phase and into the integration phase, with WBA becoming part of the new status quo in our training program.
Implementing WBA involves extensive time, energy, and negotiation to define and describe EPAs, develop an IT platform, and introduce new concepts to faculty and trainees. Our experience has taught us that this is just the beginning. Sustained energy, particularly directed at motivating intrinsic behavioral change, is essential for success. In the words of George Bernard Shaw, “Progress is impossible without change. Those who cannot change their minds cannot change anything.” It is imperative for proponents of the CBME agenda, including elements like WBA, to grasp the intricacies of change and adeptly leverage available tools, frameworks and theories, to drive change effectively.
About the author: Daniel Nel, MD, is a General Surgeon at the University of Cape Town, South Africa. His academic interests include breast oncology and surgical education.
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