By: Anna Oswald (@AnnaOswald2) and Alicia Strand
Implementing Competency Based Education (CBE) at a school level can be a real challenge for both individual postgraduate training programs and our University structures that oversee and support them. These challenges are many, but include ensuring clear and consistent communication and expectations, determining readiness for change, outlining tasks/timelines for implementation, facilitating faculty development, sharing resources and best practices and providing central support and oversight. While postgraduate medical education (PGME) offices almost universally strive to support training programs in this change, their resources vary, and they may struggle to establish visibility and supportive relationships with the large number of individual programs. There are many ways to approach institution level support, but we would like to share one model in hopes that others may find some valuable tips and learn from our struggles.
At the University of Alberta, we have been using a semi-structured interview process to build relationships with programs, to introduce change management planning and to support successful CBE implementation across multiple postgraduate training programs at our institution.
Our central PGME competency based medical education (CBME) team assembles interview triads that include a clinician educator, a program coordinator and either a second clinical educator or an education specialist to conduct semi-structured interviews with targeted clusters of local program directors, program administrators and CBME leads within each specialty training program as the program progresses through their specialty’s staggered national CBME curriculum/assessment design process. We developed a standardized interview template and refined it over time to ensure key topics were covered in each interaction. Interviews typically last about an hour but range from 30-90 min.
We start the interviews with an in-depth discussion of the program’s context including the general experience level of the program director and administrator in medical education leadership and with CBME topics, the number of government versus externally-funded trainees, the number of teaching staff and their remuneration systems (e.g. fee for service versus salaried vs mixed), the ease of engaging staff in teaching within the program to date, the number and locations of teaching sites, any existing accreditation challenges, the number and type of off-service rotations the program’s residents complete and any competing change initiatives within the program or clinical work environment. This allows us to really get to know the program. We then go on to do a brief inventory of existing assessment methods, frequency of direct observation with feedback in the existing program, level of familiarity of the general faculty members with CBME and we explore possible supports and champions within the program who may take on roles such as competence committee chair and members. This allows our central PGME CBME team to better anticipate potential areas of strength and possible struggles with the transition. From there we shift to address the program’s stage in their national CBME design, the program director’s level of participation in the national CBME design workshops, the number of entrustable professional activities (EPAs) set nationally, the distribution of EPAs across training stages, the required training experiences (RTEs) set nationally and any concerns about the ability of the program to provide clinical teaching settings for learners to develop competence in all the expected national EPAs and to complete all the RTEs. Next, we review the service implications for day and nighttime coverage that might be impacted by any potential changes to off-service rotation by residents in the program and by residents from other programs who come for off-service rotations with the program in question (e.g. how would your program manage if residents from other programs dropped their rotations with your program?). Finally, we review the PGME office’s curated CBME resource site highlighting key resources and we outline the upcoming plans to support their program through monthly CBME group implementation meetings in the year prior to their CBME launch and central electronic platform set up.
Our team has learned a lot over the course interviewing more than 50 program teams. Initially we met with each program three times for interviews (after each of their three national specialty design workshops) but this soon overwhelmed our capacity and so we scaled back to one interview per program team. Through our experience we realized the value of meeting with programs earlier in their process and shifted our interviews from after the third workshop to earlier stages of their disciplines’ national CBME curriculum/assessment design process. We soon learned how critical it was to repeat these interviews each time a new program director took over as we learned (the hard way) that handover practices were variable. This allowed us to build a relationship with the new program team so they know who we are and what we can help them with and allowed us to determine what supports they need, to make them aware of common process expectations, and to share resources.
Overall, these interviews have been allowing our team to build relationships between the central PGME team members and the individual program team members, diagnose readiness of individual programs for CBME implementation, clarify misconceptions about the intended model and processes, identify barriers and solutions at a program level, share best practices, convey policy expectations and offer support and faculty development. This has also been a really rewarding part of our role as central CBME supports as it creates a more personal connection with the programs we serve. We have shared our interview template with several schools across Canada and continue to build on this strategy in planning for the maintenance phase of supporting CBME programs. Please reach out if you’d like to hear more!
About the author:
Anna Oswald, MD, MMEd, FRCPC, is a Rheumatologist and full Professor in the Department of Medicine at the University of Alberta (U of A) in Edmonton, Canada, with an adjunct appointment to the Faculty of Education at the U of A. She is a Clinician Educator for the RCPSC, where she is an active contributor to many aspects of their Competence by Design (CBD) initiative including as member of the Competence by Design Steering committee. She is also the U of A Director of Postgraduate Medical Education Competency Based Medical Education. Through these roles she brings in depth experience of the practical challenges of implementing a large-scale transition to competency based education across a wide spectrum of programs and settings.
Alicia Strand, MD, FRCPC, is a General Internist and Assistant Clinical Professor in the Department of Medicine at the University of Alberta (U of A) in Edmonton, Canada. She is the Assistant Director of Postgraduate Medical Education Competency Based Medical Education at the U of A. She is also Associate Program Director of Assessments and Program Evaluation for internal medicine residency program at U of A, and is completing her Master in Health Professions Education at the University of Illinois at Chicago.
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