MedEd 2.0: Competency Based Medical Education, by Eric Holmboe, MD : Chapter 2 of 6



this is a somewhat busy slide but I think it's very important this is a wonderful study from Carroll Karachi Oh published enactment medicine almost ten years ago and I want to highlight the column on the right that really shows the differences in a competency-based system versus a structure process system or our old traditional model a couple things worth highlighting you'll notice that the driving force for the process of learning needs to be the learner not the teacher the learner has to take on a much more active role in a calm sea based system which I actually think is a very good thing you'll notice that the path of learning which traditions been hierarchical it's kind of like a teacher filling up students as if they were a vessel pouring knowledge into them now becomes much more non hierarchical where the teacher and student become partners working with each other to figure out how to fill gaps and help the person progress most effectively and the responsibility for the content has to be shared the goal of educational counter is not so much acquiring knowledge it's not applying knowledge that becomes a very important distinction and with regard to assessment tools we need things that are much more objective where possible but more importantly need to be authentic they need to mimic the real task of what people are actually going to do and we need to get away from using what I call proxies or what Kara called proxies such as if they can present a patient at morning report they must have been able to take a good history and physical what we've learned from research is that's just not true and so more authentic assessment would be you go and watch them with a patient taking a history and physical instead of having them tell you how that history and physical went the setting for evaluation is less removed or cast ulti but now based on more direct observation right again you watch what they do and more importantly instead of using a norm-referenced framework for evaluation such as well you know compared to Carol Joe seems to be doing pretty well and it's about the same level you would instead compare Joe and Carol to a criterion reference standard what is it they should be able to do so for example from shared decision-making we know that there are certain behaviors the part of the physician that make it more likely a patient won't hear to therapy did Joe or Carol actually do those behaviors that becomes the most important piece and all this may feel somewhat paradoxical the competency-based system relies much more on formative assessment that type of assessment that's used to provide feedback then on summative assessment an example of someone says would be the board certification exam that my organization delivers I certainly don't want to wait until somebody's taken three years of training to find out on a multiple-choice exam that they don't have sufficient knowledge and the ability to use that knowledge to be a physician formative assessment done much earlier in the process should have made that determination much earlier and it's not only fair for the trainee but actually make sure that trainee reaches the highest competence they possibly can and as I mentioned before variable time is a possibility in competent based education but I don't think right now it's the thing that should receive our greatest emphasis I think what's most important about this shift is that we measure what people are actually doing and are able to tell the public that we graduate somebody they are truly ready to enter unsupervised practice because the assessments and the curriculum are well aligned with the competencies they need to be effective independent physicians now another way to think about this and the importance of assessment comes from George Miller's famous assessment pyramid at the bottom of that pyramid is knowledge that's the foundational thing that we all need to know is I like to tell people you can't have an empty hard drive a Homer Simpson like hard drive just isn't going to cut it and so knowledge is still important and we can measure that with a multiple-choice exam and we can actually do that quite well in other techniques in these exams like extended matching your critical response questions can also get it whether or not the person knows how to do something shows how type assessments are very important and they're being used routinely particularly among medical students and these are the standardized pay Asians and other types of simulation they tell us if somebody has the capacity or the capability to actually do particular skills or have particular knowledge but what's most important is what they do that's called performance when they're caring for patients in the actual clinical care context can they take care of those patients effectively and so faculty observation that was highlighted on the previous table from care karachi is critical and although some people have put faculty observation in their shows how i believe it sits at the top of the pyramid and more importantly if we think about that pyramid now is the tip of a spear guess who's at the tip of that spear it's a patient so how well we observe how well we assess our trainees is absolutely critical so with that kind of background of what constant based medication is and the definitions of it let's now think a little bit more about evaluation frameworks and language why is this important well one of the things that challenges all of us is we often don't have a shared understanding that some of this language or these terminologies or frameworks are very difficult for all of us to kind of have a shared understanding and so that's an important next step to fully realize the potential of a calm sea based system so let's explore some of those let's start with a simple definition what exactly is a framework well this is right out of Webster's dictionary it's simply a skeletor structural frame a basic structure such as of ideas and finally it serves as a frame of reference and I think this last one frame of reference is very important from us we need to be able to have a frame of reference that we can go back to to make sense of the things we observe our trainees doing it makes sense of the information and data about their performance and as Marvin Dunn pointed out these egv competencies are simply a framework or frame of reference for education assessment they are the organizing principles to frame or discussion in to design our curriculum this is the ACGME or ibms framework well known to all of us these are the six general competencies and recently as you know procedural skills was added to the patient care competency but these are the six general competencies we use as our framework for both training and now for maintenance of certification by all 24 of the specialty boards there are other frameworks that sometimes can be helpful none of these are mutually exclusive and they can actually be kind of mixed and matched to meet particular needs I'm going to walk through each of these it's just kind of some background that hopefully will give you again some kind of frames of reference so to help me make sense of what you're trying to do particularly when assessing your trainees let's start with the KSA or knowledge skills and attitude framework this is what loop and Gera would call an analytic framework we break apart the competency into smaller component parts okay Eagles knowledge s equals skill and you can see on the slide there there's some examples of what those skills might be such as information gathering skills ability to use that knowledge such as clinical judgment in management skills and then finally attitudes are very important such as professionalism in humanism so this is again a particular type of framework that can be very helpful in breaking apart certain competencies to get a better understanding of them the rai model is also a helpful model that's been used particularly for medical students on clinical kirk ships it was developed by Lupin Karen Gordon all in the 1980s and it was developed at the uniformed services University of the Health Science to help them evaluate students during their clinical clerkships in the third and fourth year Luber first this is a synthetic model where he pulls together particular elements to provide a developmental kind of evaluation of the student so for example reporter is a medical student who can collect an accurate history and physical and report that information back in a coherent efficient frame to the attendings or the team that would be a reporter and for Lu a third year medical student on their clerkship must be able to reach the reporter level in order to pass the rotation and interpreters now somebody who can not only collect and make and report back the information but they cannot make sense of it they can interpret what the information tells them about the patient such as be able to create at least a general differential diagnosis for common conditions a manager is somebody who can then take that interpretation and begin to at least develop a draft plan for what you might do for that patient how you might treat them what antibiotic might use for example for pneumonia what tests might be needed for this patient to complete the workup and a really high functioning student is somebody who can educate others on the team relative to the patient in front of them very few students will actually reach this level and a lose system people who reach the manager level are considered honor students in their third year now these are helpful frameworks but for us in residency and fellowship training we probably need to bump them up one additional level

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