#7 Transforming Medical Education: A Competency-Based Time-Variable Approach

January 25, 2022 | By Molly Heublein

with Dr. Ben Kinnear 

Summary

Listen as our guest Ben Kinnear MD @Midwest_MedPeds from the University of Cincinnati dives into Competency-Based Time-Variable Medical Education, sharing his expertise and experience with starting the CBMETV pilot program TIMELESS (Transitions in Internal  Medical Education Leveraging Entrustment Scores and Scales).  We explore some of the challenges including assessment bias, cost, professional identity formation and scaling in a broader system.  Be inspired to challenge the system and train the next generation of medical professionals!

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Credits

• Producer/Hosts/Writers: Molly Heublein, MD; Era Kryzhanovskaya, MD  
• Infographic, show notes, and Cover Art: Andrew DeLaat 
• Guest:  Ben Kinnear, MD

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

• Intro, disclaimer, guest bio 
• Picks of the Week
• Case 1 from Kashlak 
• CBTV Definition 
• Approach to implementing CBTV in practice 
• Learners Role in CBTV Programs 
• Assessment Bias in competency based programs
• Master Adaptive Framework Model 
• Take Home Points from Dr. Kinnear 
• Outro

Competency Based Time Variable Medical Education Pearls

1. The core goals of CBME are aimed at training learners to provide the highest quality health care for the needs of the patients and health care system. 
2. Competency-based time-variable systems should provide flexibility for learners within a curriculum to maximize their growth. 
3. There’s no “right way” or “one size fits all approach” to graduate medical education but what is needed is innovation and finding new, better ways to educate and prepare the next generation of physicians.

In-Depth Show Notes 

Competency Based Medical Education 

Competency-based medical education (CBME) is an outcomes-based approach. Start with what you want your learners to be able to do and work backward from there to define your curricula and assessment system. The CBME core competencies below can guide implementation:
– Outcome competencies – what knowledge/skills/attitudes do you want your learners to have (hopefully based on needs of patients)

– Sequenced progression – don’t expect novice learners to do the hardest things out of the gate

– Tailored learning experiences – each learner is likely to have a unique trajectory/needs

– Competency-focused instruction

– Programmatic assessment – lots of types of assessments from many different observers over time integrated in a systems-based approach

Time-variable training is, for many, a corollary of CBME, but not necessarily core to it. In CBME, assessments ideally address all the relevant competency domains of the student/learner and should be based on data.  Competencies should be based on what skills are needed to meet the needs of patients and society.   This approach utilizes time as a resource instead of a measuring stick (Frank 2010).  

Time-Based Medical Education

Time-based education was adopted following the standardization of medical education early in the early 1900s, and it served as the new template which medical schools and medical education would utilize going forward.  Time-based programs may create pressure to move learners through to keep the learner “on track,” avoiding interruption of their career progression.  Time-based systems often have a set schedule of clinical experiences the learner must have to successfully graduate and only deviate from this schedule when absolutely necessary.  Such programs generally provide minimal flexibility around the pre-defined requirements. 

Benefits for Competency-Based Medical Education (CBME) and Time-variable CBME (CBTVME)

The program is based on the learners and their educational and developmental needs, instead of running on a time-based curriculum with a set end date.  The end goal is that learners have the knowledge, skills, and attitudes they need to provide safe, effective patient care and thrive in their future careers.  Goal competencies of the program should ideally incorporate opinions from all levels including learners, educators, patients, and the public’s needs .  Ideally, time-variable systems would provide more flexibility in the learners education, allowing them to be promoted when they are ready (no sooner or later) and demonstrate the competencies needed to care for their communities (Lucey 2018). 

Role of the learner in Competency-Based Medical Education

Learners in a competency based program have agency in their own education, communicating areas in which they feel they need more growth or training. Learners can drive their progression by using programmatic assessment data, feedback, and coaching to guide their learning. 

EPAs (Entrusting Professional Activities) in a competency based system

EPAs are aimed at utilizing trust within a competency-based system to better assess a learner and their clinical preparedness.  Entrustment brings patient care to learner assessment by deliberately stating how much supervision is required for various patient care tasks (Touchie 2021).  

Examples of this in practice:

During the COVID pandemic some medical schools  graduated students early.  This is an example of time-variable medical education in practice (Caretta-Weyer 2021).  If these students were ready for the next phase, why aren’t we doing this more often?

The EPAC is a consortium of pediatrics programs that have been piloting CBTVME for several years (Andrews 2018). 

The TIMELESS Pilot Program–Implementing CBTVME 

TIMELESS, Transitions in Internal Medicine Leveraging Entrustment Scale and Scores, is a pilot competency-based pilot with a subset of residents at the University of Cincinnati in the internal medicine residency program. In the pilot, they utilize internal medicine EPAs and their program of assessment to guide promotion decisions in a time-variable manner. The residency’s clinical competency committee synthesizes programmatic assessment data to determine when TIMELESS residents are ready to progress through residency. The program is actively assessing the program’s effect on learner growth, how they relate to their colleagues, and their ability to ask questions and seek feedback.  Dr. Kinnear is hopeful the time-variable system will open new opportunities and innovation at addressing bias in learner education and in training assessment. 

Challenges to CBTVME: 

Making defensible decisions regarding the learner and their clinical readiness

Practically making the program work in a larger rigid system with limited flexibility

Assessment bias of the learner – Racial, gender, personality etc- we need to watch out for systematic bias .  This already exists in medicine (Low 2019, Gorth 2021), and we need to encourage innovation to mitigate this.  Rater trainings may be partially helpful, analyzing ratings after the fact for signs of bias and adjusting may be helpful, moving away from human assessment and toward assessment based on clinical outcomes (with the caveat that these are not bias free either) could be a positive direction.

Promoting a growth mindset. Does linking assessment to progression through residency increase the stakes for residents and reinforce a performance-based mindset rather than a growth mindset?

Benefits of CBTV:

It really encourages innovation and deliberation around assessment and advancement.  In the current time-based system, unless a learner is an outlier, they will progress; it is almost a passive system.

It may foster lifelong learning, allowing trainees to explore areas that they need more work in.

Dr Kinnear stresses this is a work in progress, with iterative improvements.  There is no right way to teach medicine, and the more we explore and innovate we can improve further.

Master Adaptive Learner Framework Model

The Master Adaptive Learner Framework as a basis for learner’s developing into the clinicians of the 21st century.  The goal is that by training students to be master adaptive learners, we can give them tools to adapt and develop into self-directed, self-regulated, and lifelong workplace learners. The Master Adaptive Learner (MAL) framework is based on learners having a growth mindset and taking a deliberate approach to learning where they continually adjust and innovate as new information comes up and best practices evolve–demonstrating adaptive expertise in response to challenges in everyday work. This means emphasizing learner directed growth without need of a coach or preceptor.  The MAL approach–applying a metacognitive process to ones learning to develop adaptive expertise–is thought to be heavily influenced by curiosity, motivation, growth mindset, and resilience.  If you want more on the MAL, check out the book or the AMA has put out quick summaries as well.  (Cutrer 2017) 

Other Stuff

Citations

Jonker G, Ochtman A, Marty AP, Kalkman CJ, Ten Cate O, Hoff RG. Would you trust your loved ones to this trainee? Certification decisions in postgraduate anaesthesia training. Br J Anaesth. 2020 Nov;125(5):e408-e410. doi: 10.1016/j.bja.2020.07.009. Epub 2020 Aug 5. PMID: 32768180.

Van Melle, Elaine PhD; Frank, Jason R. MD, MA(Ed); Holmboe, Eric S. MD; Dagnone, Damon MD, MSc, MMEd; Stockley, Denise PhD; Sherbino, Jonathan MD, MEd; on behalf of the International Competency-based Medical Education Collaborators A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs, Academic Medicine: July 2019 – Volume 94 – Issue 7 – p 1002-1009. doi: 10.1097/ACM.0000000000002743 

Dr. Kinnear advice: There isn’t such a thing as a “Storm (black) cloud Phenomenon” in medicine (Ong 2018), and that physicians have more agency in their hospital workload and changing your approach to extremely busy times can be beneficial. 

There’s no “right way” or “one size fits all approach” to graduate medical education but what is needed is innovation and finding new, better ways to educate and prepare the next generation of physicians.

Links

Book by Frans Johannson The Medici Effect: looks at how different disciplines can learn from each others

Recommended Books By Dr. Kinnear: Grit by Dr. Angela Duckworth; Mindset by Dr. Carol Dweck;  The MVP Machine by Ben Lindbergh and Travis Sawchik

Additional Learning Resources: 

Practical Guide to the Evaluation of Clinical Competence by Eric S. Holmboe MD MACP FRCP, Steven James Durning MD PhD, Richard E. Hawkins MD FACP

Pusic MV, Santen SA, Dekhtyar M, Poncelet AN, Roberts NK, Wilson-Delfosse AL, Cutrer WB. Learning to balance efficiency and innovation for optimal adaptive expertise. Med Teach. 2018 Aug;40(8):820-827. doi: 10.1080/0142159X.2018.1485887. Epub 2018 Aug 9. PMID: 30091659.

The Master Adaptive Learner: from the AMA MedEd Innovation Series by William Cutrer, Martin Pusic, Larry D Gruppen PhD, Maya M. Hammoud MD MBA, Sally A. Santen MD PhD 

International Clinician Educators Blog: https://icenetblog.royalcollege.ca/about/ 

Goals

Listeners will become familiar with the concept of competency based, time variable health professions education. 

Learning objectives

After listening to this episode, listeners will be able to…

1. Define competency-based, time-variable health professions education (HPE)
2. Describe the novelties of or differences between CBTV and other approaches to HPE
3. Recognize the benefits and challenges of implementing this model at your institution

Disclosures

Dr Kinnear reports no relevant financial disclosures. The Curbsiders Teach team report no relevant financial disclosures. 

Citation

Kinnear B,  Kryzhanovskaya E, Heublein, M. “#7 Transforming Medical Education: A Competency Based Time Variable Approach ”. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach January 25, 2022.