This week we will be pulling another CBME related post from the archives. This Blog was originally posted on August 20, 2019 and has been very popular over the years. We hope you enjoy.
The Story of Jane Miller MD: Articulating CBME Through Narrative Story Telling
Authors: J. Damon Dagnone (@Damonjdd1); Denise Stockley (@denisestockley); Leslie Flynn (@flynnlv); Jenna Healey (@jennachealey); and, Richard Reznick (@DeanOnCampus)
The shift towards Competency-Based Medical Education (CBME) is upon us, but many outstanding questions remain (Boyd et al., 2018, Salim et al., 2018). For many educators, it remains difficult to imagine what physician training in a CBME system will look like moving forward, and how CBME aspires to improve the training experience of learners, and ultimately, the provision of patient care. To this end, we present the hypothetical story of Jane Miller MD, and her experience with CBME during medical school, residency training, and through the first decade of her career. Jane enters medical school as a high-achieving student, and while the particulars of her story may be unique, the challenges she faces are universal. It is our hope that this narrative vignette, while fictional, will illustrate the many ways in which CBME can transform medical training and positively impact patient care.
Vignette: The Training of Jane Miller MD
This vignette follows Jane’s lived experience within a CBME training model, from her admission to medical school through the early years of her practice. Each section of the vignette is interspersed with a short commentary on how Jane’s story illustrates the key benefits of CBME for both Jane and her patients.
Jane applied to medical school at 22 years old, after completing a combined Human Sciences & Liberal Arts university degree program. For Jane, the process of applying to medical school involved three stages of competency assessment: a one-month placement and group learning experience at a local university hospital under the supervision of a physician, clinical nurse, and patient advocate; a multi-source assessment by community and faculty members based on her academic performance, communication skills, and problem solving capabilities; and a third stage of reflective practice including an essay regarding her experiences in the hospital and in-person interviews with community, physician, and allied healthcare providers.
This multistage admissions process allowed the committee to evaluate Jane’s interpersonal, communication, and critical thinking skills in both self-directed and team-focused settings. Traditional emphasis on metrics favoring rote memorization and test scores, including the Medical College Admission Test (MCAT), were discarded in favor of identifying candidates who could sustain a growth mindset (Dweck, 2016) and develop strong reflective practice (Mamede, 2004).
Jane’s training in patient care began immediately upon entering medical school. Moving beyond the traditional classroom, Jane was exposed to multiple learning environments including community placements, hospital clinics, the emergency room, the operating room, and in-patient wards. These early clinical experiences were supplemented with small group learning in weekly simulation/ reanimation labs, independent online learning, and integrated multi-disciplinary and/or inter-professional classroom environments. Peer tutoring, faculty mentoring, and electronic teaching modules were the preferred methods of medical knowledge acquisition. The curriculum ensured longitudinal exposure to numerous medical and surgical patients, as well as multiple opportunities to assess undifferentiated patients with acute care presentations in the emergency room (ER) and family medicine clinics. Clinical rotations in early medical school involved following patients through their care pathways across multiple care environments, rather than being placed in static single specialty rotations. Basic science education lectures and small group sessions were organized in a spirally integrated fashion throughout the first three academic years to reinforce the scientific foundations of the medical expert knowledge base and applied to the clinical encounters.
In the middle of Jane’s third year of medical school, the electronic portfolio of her cumulative assessments, along with reference letters from her clinical supervisors, supported her application to follow an individualized learning trajectory towards her chosen specialty of General Internal Medicine (GIM). With approval from the Undergraduate Medical Education committee, and in partnership with the core Internal Medicine (cIM) Program, Jane received early acceptance to her graduate medical training in lieu of completing a 4th year of medical school, and began a customized twelve-month transition to Internal Medicine similar to the Education in Pediatrics Across the Continuum (EPAC) program initiated in the United States (Andrews 2018).
Early immersion in patient care environments allowed Jane to identify her preferred specialty at an earlier stage of her undergraduate education, which in turn allowed her to customize her training pathway and focus on areas that were most relevant to her future practice. For Jane, the opportunity to consolidate skills in the specialty of her choice was hugely motivating and, with a clear path to residency, allowed her to focus on becoming a proficient generalist doctor in Internal Medicine. Jane’s learning of prerequisite knowledge for Internal Medicine was enhanced because it was clinically situated and anchored within the day-to-day team functioning, rather than in a classroom with theoretical case examples. This resulted in Jane more quickly integrating herself onto the IM unit team, participating in team meetings, and receiving formal integrated feedback from patients and family that contributed to her electronic portfolio.
After receiving early entry to begin her Internal Medicine residency training from medical school, Jane began her IM core certification prior to her General Internal Medicine (GIM) specialist training. To support her development over the duration of her training, a faculty IM advisor met with Jane quarterly to assist with tracking her individual performance targets. From the outset of her IM training, she was assessed across a competency framework (the Royal College of Physicians & Surgeons Competence by Design model) that included stage-specific required training experiences and regular assessment of stage-specific entrustable professional activities (EPAs) along with their associated milestone competencies. Faculty supervisors, allied health care professionals (eg. registered nurses, social workers, rehabilitation specialists), peer physicians, patients, and family members were all involved in her performance evaluations. Throughout her residency training, Jane excelled in many areas during the first 18 months of her residency training and completed all EPAs for the Transition to Discipline and Foundations of Discipline stages. When compared to the electronic national database of cIM programs, Jane’s time to completion was within one standard deviation of the national average. She was also nominated for an award highlighting outstanding patient and family-centered care in oncology, which reflected her passion for working with this particular population.
During the early period of transitioning to the Core of Discipline stage, which involved increased clinical care and supervision duties, Jane had difficulty with the responsibilities of concurrently managing multiple patients on the ward, the supervision of junior learners, and seeing new patient consults from the ER. This resulted in Jane becoming overwhelmed at times while on-call overnight, and this was reflected in many of her early assessments. To address the challenges she was facing, Jane and her faculty advisor designed an individualized learning plan to help develop new strategies for prioritizing patient care. This included performing buddy call with a more senior resident for a period of one month, creating an algorithm of when to call for help during busy times, and increased support from her attending physician during times when she was on-call. Three months later, Jane’s assessments were much improved and she felt confident, along with her faculty advisor, to resume her regular schedule.
To maximize patient safety and individual competency development, Jane was assessed regularly by supervisors on a number of EPAs and received additional on-call support when it was apparent that she was struggling to develop competency with her new responsibilities in the Core of Discipline stage. Using this system, Jane became more thoughtful about when to call for help and prioritizing patient interactions when faced with multiple demands. Moreover, the need for successful completion of all EPAs and required training experiences in each stage ensured that Jane would only advance through her training once she demonstrated independent performance of all necessary competencies. Using her personal electronic portfolio, her regular meetings with a dedicated faculty advisor allowed a customized plan to be initiated for Jane in a timely manner. With clearly articulated and mutually agreed upon learning and performance goals, learning modifications were easily integrated into her daily schedule.
Jane completed her General Internal Medicine (GIM) specialty exams after 3.5 years, but delayed her final stage of specialist GIM residency training to take a six month leave to get married and volunteer at a new medical school under development in Ethiopia. After her return to Canada, Jane fulfilled all GIM competencies required for her transition to independent practice and was given full certification by her accrediting body. She also chose her first continuing professional development (CPD) faculty mentor. This mentor met with her biannually to assist with the development and implementation of an individualized CPD strategy.
Jane began her career working at a large community hospital in an urban Canadian city. She worked full-time as a clinician, and as per the certification standard for her specialty, she catalogued her patient encounters to demonstrate her exposure to the full breadth and depth of GIM. Additionally, she participated in quarterly simulation skills training days at her university training centre. During the first year, these CPD workshops focused on a combination of procedural competencies on partial task trainers, team leader acute care/resuscitation competencies using high fidelity simulation-based resuscitation suites, and on formal debriefing of critical events for inter-professional teams.
Trainees will have diverse interests and life experiences, many of which complement physician development. CBME acknowledges this diversity by allowing trainees to “pause” their training for defined periods of time. This flexibility enabled Jane to pursue personal goals that renewed her passion for medicine and directly benefited patients in a low-income country. On entering independent practice, Jane continued to develop her skills through regular inter-professional simulation training and the practice of cataloging her patient encounters in order to track her case mix and outcomes. In partnership with her faculty mentor, Jane maintained her reflective practice regarding the development of personal habits and practice patterns that prioritized her own well-being as well as the delivery of high quality care for her patients. The importance of creating opportunities for flexibility during training, which can include taking personal time to promote better work-life integration, cannot be understated, as it holds the potential to combat increasing rates of physician burnout. It is difficult to predict whether CBME will affect the overall culture of practicing medicine (ie. physician as person), but the assumption can be made that habits and practice patterns begin to take shape before independent practice. A flexible training framework can help to create professional norms that promote work-life integration and support both personal and professional development.
During her first five years of practice, Jane had two children with her partner. She adopted her first child and elected to take 3 months of maternity leave, with her partner taking 6 months of parental leave on her return to work. With her second child, Jane took leave during the last month of pregnancy, followed by the next 6 months to be at home with her newborn baby and now 3-year-old son. For much of this time, Jane was eager to participate in committee and academic meetings whenever she was able (in-person or via Skype teleconference). On returning to clinical work at the end of her second maternity leave, Jane participated in a 1-month transition phase of individualized professional development and ‘return to practice’ enhanced training sessions that were provided by her hospital and supported by her faculty mentor.
Maintaining practice competencies can be challenging during periods of clinical inactivity due to parental leave, personal illness, or other life circumstances. Offering concrete support for periods of clinical leave and subsequent reentry into the workplace, no matter the reason for the leave, ensures smoother transitions, enhances patient safety, and protects against burnout. Through strategic partnerships between hospitals and university centres, education goals for independent practitioners can support ongoing individualized physician training by creating a supportive working environment with opportunities for continuing professional practice.
After 10 years of practice in GIM at her local community hospital, Jane entered a combined work/study program in oncology at a university teaching hospital 50km away, where she pursued new competencies in patient & family-centred communication skills, medical oncology medicine, pharmaceutical sciences, rehabilitation therapy, and nursing care. Tuition for this program was paid for by a governmental bursary program for enhancing physician skills. The program appealed to Jane for many reasons. Most importantly, Jane was motivated to enhance her skills in oncology care and she was interested in new challenges to go with her pre-existing passion. Other reasons included the flexible training schedule and cross-disciplinary competency training. Jane was joined in her university training program by a number of health care professionals from other hospitals and health centres within her region. For the duration of the enhanced oncology training program, Jane spent 3 days a week continuing to care for her patients at her home hospital in General Internal Medicine, and 2 days a week training at the university hospital.
Jane elected to continue for a second additional year of multi-disciplinary training in oncology. Specific competencies that Jane focused on during this time included the coordination of multi-centre pharmaceutical drug trials and the administration of novel health systems. She also championed the use of ‘FITBIT physiological monitoring’ to track automatic care pathways based on daily variations in vital signs, subcutaneous bloodwork, and sleep-rest cycles for rapid and algorithmic responses for patients self-reporting to hospital. Achieving these focused competencies, along with the longitudinal components of her oncology training program, Jane decreased her GIM responsibilities at her local hospital to become Director of the new “Home Assist” Medical Oncology Team, along with a nurse practitioner colleague at the university hospital. Taking advantage of her new competencies, Jane became the lead for developing enhanced longitudinal patient oncological care pathways, allowing cancer patients to access their care providers in a timely fashion. This resulted in dramatically improved patient satisfaction surveys, less frequent ER visits, reduced complication rates, and resource savings due to improved efficiencies in care.
In the first decade of Jane’s career, she started a family, began her General Internal Medicine practice, and sought out new opportunities for skill development in oncology. Because of the flexibility of the work/study program and the formal supports in place from her home hospital, Jane was able to develop an enhanced competency portfolio that leveraged her passion and expertise. With her newly acquired skills, Jane was able to take on a leadership position and innovate a program that enhanced patient care in measurable ways. Using the program’s success as a model, Jane was able to assist other leaders in designing and applying for funding to support similar innovations throughout her hospital.
Years later, at Jane’s 20-year medical school reunion, she discovered that many of her classmates had followed similarly diverse and non-linear paths. Some of her classmates had become full-time educators or administrators, while others had developed competencies in secondary specialties or allied health care professions. Most notably, she was most happy to learn that her classmates had also taken advantage of achieving many other new competencies, regardless of what specialty they started in.
With a focus on accruing specific competencies rather than on following a specific timeline, competency-based medical education creates opportunities for physicians to become more well-rounded and versatile healthcare professionals. This versatility is more patient-centered and also physician-friendly compared to previous training models. It allows physicians to better serve their patients and communities through acquiring novel sets of competencies that are necessary to provide quality care in their local contexts. Physicians will also feel empowered to adapt their skill sets according to these local contexts, thus increasing their sense of work satisfaction. Lastly, physicians will be able to establish a greater work-life integration by having the flexibility to attend to their personal and professional needs or interests, without compromising their competence or confidence to provide quality patient care. Taken together, a fully integrated competency-based medical education approach could result in greater happiness and health for both physicians and their patients.
Moving forward, CBME implementation offers opportunities for enhanced medical training and continuing professional development. As medical educators and leaders, a key focus must be to develop a body of evidence that satisfies these assumptions. CBME is still in its early days, and the lack of observable benefits to patient care and a general resistance to change must not deter us from our goals. Jane Miller, used as a narrative vignette, helps demonstrate that a new future is possible – and that creative and innovative approaches to training and practice can make the hypothetical possible.
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