CBME, by the ICBME Collaborators, Competency-based medical education
by ICE Blog Admin

Innovating Toward Time-Variable Graduate Medical Education and the Arc of Change in Health Professions Education

By: Debra F. Weinstein, MD

I must start this post with thanks to the ICBME organizers and participants for advancing the important work of competency-based medical education (CBME), individually and collectively. Effecting change isn’t easy. Moving medical and health professions education to CBME at scale and ensuring sustainability requires patience, persistence, and a network of champions. Kudos to all. 

CBME is logical, intuitive and increasingly recognized as the appropriate foundation for clinical education. However, while progress is evident, widespread implementation is not inevitable. In this context of this uncertain trajectory, a group of us – including John Co, Mary Ellen Goldhamer, and Martin Pusic – dove in five years ago and embraced the enticing and audacious goal of competency-based time-variable (CBTV)graduate medical education(GME). Our “Promotion in Place” project1 was enabled by generous funding from the American Medical Association’s “Reimagining Residency” grant program, which ends next year. The model involves time-variable graduation from residency, with facilitated extension if more time is needed, and in-situ advancement to unsupervised practice when competency is confirmed earlier – all informed by enhanced assessment.

The wisdom of jumping ahead to CBTV-GME, before CBME reaches a tipping point, could certainly be questioned. Time-variable graduation, certification, and transition to unsupervised practice is not widely acknowledged as logical, feasible, or advisable. Yet we were inspired by Canada’s Competency by Design framework2, by the Orthopedics pilot in Toronto3 and, particularly, by the multi-site Education in Pediatrics Across the Continuum project4,5. We hoped to overcome the many obstacles to medical education innovation by developing a feasible implementation model1 and articulating its anticipated benefits and compelling “use cases” (see table).

As of now, six years later, Massachusetts General Hospital’s Pathology Residency is participating in a fifth cycle of CBTV GME, but is the only program/specialty to have launched the Promotion in Place pilot. The University of Michigan has one residency program in a surgical specialty poised to launch with support of its national specialty board. Three other specialty boards have denied program requests to provide exemptions from time-based Board requirements, though one intends to reconsider next year. 

Understandably, caution about potential risks is paramount in the health care context. If changes to physicians’ training were to undermine their effectiveness, current and future patients could suffer. But we must also recognize that many of our structures and processes in medical education are based on long-held assumptions and historic practices that were never based on evidence. 

I hope that this CBTV pilot – along with many other innovations – can move forward and yield meaningful information about how to optimize medical education. This will rely on piloting CBTV at scale, with collaboration across national oversight and regulatory organizations, identification of new funding sources, and engagement of passionate educational leaders from diverse GME programs and institutions. Perhaps ICBME’s  network of champions can help make this happen. 

Next month I’ll be assuming leadership of the ACGME and seeing these issues through a different lens, with a new set of responsibilities and accountabilities, and with aspirations for continuous improvement of medical education. I look forward to staying abreast of ICBME’s work with ongoing optimism that it will move us closer to a forward-facing, evidence-informed approach to educating the health professions workforce of the future.

About the Author:

Debra F. Weinstein, M.D. is the Executive Vice Dean for Academic Affairs and a Professor of Learning Health Sciences and of Internal Medicine at the University of Michigan Medical School, and Chief Academic Officer at Michigan Medicine.  She was previously Vice President for Graduate Medical Education at Mass General Brigham in Boston, and served as the Principal Investigator of the “Promotion in Place” grant from 2019-2021.  As of January 1, 2025 Dr. Weinstein will be the President and Chief Executive Office of the Accreditation Council for Graduate Medical Education.

References

  1. Goldhamer ME J, Pusic MV, Nadel ES, Co JPT, Weinstein DF. Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education. Acad Med, 2024; 99(5):518-523.
  2. Frank JR, Karpinski J, Sherbino J, et. al. Competence By Design: a transformational national model of time-variable competency-based postgraduate medical education. Perspect Med Educ, 2024;13(1):201-223.
  3. Nousiainin MK, Mironova P, Hynes M, et. al.  Eight-year outcomes of a competency-based resident training program in orthopedic surgery. Medical Teacher, 2018;40(10):1042-1054.
  4. Powell DE, Carraccio C. Toward Competency-based Medical Education. N Engl J Med 2018;378:3-5
  5. Andrews JS, Bale JF, Soep JB, et. al. Education in Pediatrics Across the Continuum (EPAC): First Steps Toward Realizing the Dream of Competency-Based Education. Academic Medicine, 2018; 93(3):414-420.

A note from the Blog editor

This is last blog of 2024 . Many thanks to all who have contributed to the blogs, and especially to Dr. Weinstein for completing this year’s series with an outlook on the challenges of innovation and arc of change in ICBME’s work.

ICBME is also moving to a new phase and a new name: ICBE collaborators and with  a new organizational structure. This blog will continue and we look forward to a rich series in 2025. – Olle ten Cate, PhD

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The University of Ottawa . For more details on our site disclaimers, please see our ‘About’ page