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2017 Issue 4: How we learn

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The evolution of medical education

The evolution of medical education

The competency-based model is the future of medical education. Queen's School of Medicine is the first medical school in Canada to implement the model across all 29 of its specialty medicine programs.

[The evolution of medical education]

It's time for Natasha Ovtcharenko to deliver some bad news.

Her patient is waiting on the other side of the curtain, by the window, in a hospital room at Kingston General Hospital's Connell wing. Dr. Ovtcharenko pulls back the curtain. Joined by hospital staff, she approaches the patient and his family, who are clustered around the hospital bed. A brief bit of small talk and then it is time to provide the diagnosis. Expressions of hope turn into slight frowns. Once Dr. Ovtcharenko is done, she and the staff excuse themselves while the family consider their options. The curtain is closed around them once again.

Out in the hall, David Taylor is ready, tablet in hand. Dr. Taylor, program director of the core internal medicine program, has some positive feedback for his junior counterpart. While Dr. Ovtcharenko was updating the family on the patient's situation, she was also being evaluated. Dr. Taylor was logging what he saw in an online dashboard for residents that tracks their feedback and progress. A few taps of the tablet, a quick conversation with Dr. Ovtcharenko about her approach, and the review is complete. While supervision and feedback of residents working with patients have always been a part of the rounds in teaching hospitals like KGH, this interaction is the sign of something new.

That brief exchange, about five minutes in duration, is the realization of a vision years in the making, and it represents a significant change in the way medical schools evaluate residents training to become practising physicians.

Medical education has, for decades, relied on the idea that, if residents spend enough time on a certain skill or discipline and receive weekly verbal feedback from hospital staff, they will eventually master their required skills and be ready for their exams and the working world. However, added pressures on residents and the hospitals they work in has reduced the amount of time most residents spend "at the office". These pressures range from the ever-expanding body of medical knowledge and essential patient safety initiatives to a reduction in duty hours coupled with an appropriate focus on trainee wellness.

Plus, this existing time-based regime does not take into account the different pace of learning that might best suit each resident. Ultimately, what the system needed was more accountability and transparency – for doctors, for educators, and for patients.

That's why, in 2014, the Royal College of Physicians and Surgeons of Canada undertook a project called "Competence by Design" – an effort to transition all Canadian medical schools to a competency-based system. This new model would mean residents are evaluated more regularly and consistently, that the reviews would help shape their learning over their residency, and that the residents can more closely monitor their own progress and performance to ensure they learn the skills they need.

The Royal College wanted all Canadian medical schools to make the transition to competency-based medical education (CBME) one specialty program at a time over five years beginning in July 2017. Just as other schools were getting ready to leave the starting blocks, Queen's University was crossing the finish line – having completed its full deployment of CBME across all 29 of its specialty medicine programs.

 


What is competency-based medical education?

CBD: The Royal College of Physicians and Surgeons of Canada

  • Competence by Design (CB) is the RCPSC's initiative to improve physician care through CBME
  • The goal of CBME is to transform medical education from time-based to a hybrid model of resident training
  • It organizes physician training around desired learning outcomes and competencies
  • Emphasizing physician education  over a continuum from residency to retirement ensures physicians continue to demonstrate the skills and behaviours needed to meet evolving patient needs

Completing the transition took Queen's School of Medicine more than two years and gave Queen's the distinct advantage of being the first medical school in North America to make the wholesale change. In addition to curriculum reform to allow for individualized learning plans, CBME also changes how residents are assessed and how their progress is monitored.

"You regularly receive formal feedback and evaluation forms, and every time there's a discussion of how I am doing, where I can go from here, what I can work on, and what is going well. It makes you more focused as you go through your days on clinical rotations because you realize, 'I need to see this, and I need to do more of this," adds Dr. Ovtcharenko. "Residency is a balance between work and education, and this makes sure that you're meeting your goals."·

Residency is a balance between work and education, and this makes sure that you're meeting your goals.

Some of the residency programs have only implemented CBME for residents who have just begun the first year of their contracts. Other programs lend themselves better to CBME-style assessments, such as emergency medicine where residents are traditionally monitored more closely. So, a hybrid solution has been implemented for senior residents in some of Queen's post-graduate medical programs. This offers the residents access to the new assessment tools while keeping to their existing learning plans.

"We have a discussion about our performance at the end of every shift," explains Kristen Weersink, a senior emergency medicine resident. "With CBME we moved from a global assessment that was often delivered verbally to something more specific with mandatory comments."


How does CMBE work?

EPA: Entrustable Professional Activity

  • A unit of professional practice (task) that can be entrusted to a sufficiently competent learner

Milestones: Meaningful markers of progression through competence

  • Learners progress through the phases of the competence continuum, meeting the milestones for each EPA
  • Once learners successfully complete each EPA (guided by milestones and enabling competencies) they can progress to the next phase of training along the continuum
  • If a learner experiences difficulty with an EPA they can "unpack" the associated milestones to focus on areas to revisit
  • Once learners successfully complete all EPAs in their current stage, they can progress to the next phase of learning

    A unique perspective

Dr. Weersink had a bit of a unique perspective on the roll-out of CBME. She had the opportunity to participate in the Royal College Specialty Committee in Emergency Medicine to develop its entrustable professional activities – tasks or responsibilities that a professional doctor will need to be able to perform on their own once they graduate. These activities shaped the assessments that underpin the whole competency-based program.

Another key piece of the program is the feedback from the residents to the faculty and program administrators. Residents regularly meet with academic advisers who check in on resident progress and obstacles, identify gaps in learning, and hear from residents about how the technology and processes behind CBME are working for them.

"The institutional support has been excellent, and this has been a huge strength for Queen's," adds Dr. Weersink. "The implementation has made us feel like we're a part of it – not that CBME is being forced on us. They have involved us and treated us like the adult learners that we are."

The evolution of medical education

So what's happening behind the scenes when faculty, senior residents, and other medical staff are evaluating residents like Dr. Ovtcharenko? Those few taps of a tablet are actually helping to shape the resident's path to the profession.

[graphic showing resident progress dashboard]
The resident progress dashboard shows how much of each stage of residency the individual has completed at any point during the program.

After the resident completes their interaction with the patient, the evaluator has to match the encounter to one of the activities the resident must perfect. They enter some details about the situation – how complex it was, what kind of patient was involved - and grade the resident's response. In a situation where the resident has to break bad news, for example, the resident might be evaluated on how effectively they communicated with the patient and their tamily and how they advocated for the patient's care.

Their progress is then measured in large part by tracking the successful attainment of defined entrustable professional activities (EPAs), with the physician supervisor documenting progress within each resident trainee's electronic portfolio. Each EPA can be broken down into defined milestone competencies, smaller developmental pieces that provide the contributory blueprint for development. Internal medicine residents, for example, must work towards specialty-specific EPAs defined in each of the four stages of residency training. In the first stage, known as "Transition to Discipline," one EPA they must accomplish is to "identify and assess unstable patients, provide initial management, and obtain help." By the time they reach the final "Transition to Practice" stage, they will be expected to "assess and manage patients in whom there is uncertainty in diagnosis and/ or treatment."

The evaluator must then indicate an entrustment score on a five-point scale, ranging from a one – meaning the resident still needs to be observed – to a five – where the resident can be left alone and can supervise other trainees. Finally, there's a comment box, a discussion of next steps, and the review is filed away. That review becomes part of the resident's online dashboard, where they can track their ongoing progress and identify other skills they need to master.

Two years of hard work

It took more than two years of hard work to get to the July launch, which included big-ticket projects, like getting the software platform up and running and updating the curriculum, and smaller but highly precise tasks, like perfecting the wording on those crucial evaluation forms. Beginning in 2015, teams of faculty, education experts, software developers, and administrators worked to finalize the tools, craft the policies, and secure buy-in.

Mary Bouchard (ConEd'12, MEd'14) was one of the first new staff hired to work on the CBME project. She joined the School of Medicine in July 2015 as an educational consultant for the pediatrics program, and she later took on similar duties in the public health and preventive medicine programs. "I was excited to hear they would be incorporating evidence-based practice into revitalizing medical education," says Ms. Bouchard. "I was maybe a little nervous in those first few days when I joined the team, but more than that, I was xcited. I like problem-solving and I like a challenge. When they explained the whole project to me and the timeline, acknowledging that my role was going to develop along the way ... I was really looking forward to being a part of Queen's innovation in CBME."

Ms. Bouchard's success led to the hiring of eight additional educational consultants across the other programs. This group meets regularly, working together to review their documents, forms, and processes. In between meetings the group members regularly stay in touch, working together to solve common problems. "I don't know that we could have done it without that distributed support network," she says. "If we had launched independently from other programs, we wouldn't have that collaboration and I don't think it would have worked."

The educational consultants are involved in project management, curriculum revision, and developing different assessment strategies. In support of their work, they run workshops for the faculty and residents and seek their opinions in order to make updates. Martha Munezhi, Ms. Bouchard's counterpart in the internal medicine residency program, says the feedback has so far been quite positive and the early results have been promising. "We definitely have a jump in the number of assessments being conducted with the residents right now – which means more feedback for the resident, more time to work on the feedback, and, in the end, better doctors and better patient care and outcomes."

With a higher quantity of assessments being conducted, the focus is now turning to quality – ensuring the forms being used are suitable for the task, addressing faculty and resident concerns, and helping both groups to navigate the technology. The software platform also allows them greater insight into the assessment trends, such as how frequently a particular resident or resident cohort is being assessed and where the gaps are. "That will help us to ensure residents are having their assessments done, determine what the problem might be, and follow up with the resident to make sure they get feedback. Residents and faculty can both trigger assessments, so the online evaluation system is both learner- and faculty-driven," says Dr. Munezhi.

Now that the July launch is a few months in the rear-view mirror, you might think things would have slowed down. However, Ms. Bouchard notes, this is still a new and innovative approach to education, and the School of Medicine wants to make sure it gets it right. So, the educational consultants – working with the rest of the CBME team – continue to study and evaluate the program to make sure it is delivering the results it was designed to create. Being engaged in those conversations since the early days of the project has helped Ms. Bouchard see the change that has occurred – not only in the residency programs but also in the hearts and minds of the faculty and staff.

"Looking back two years ago at the program leader workshops that were happening at that time, there was a lot of uncertainty around the change. There was push-back and a lot of conversation around 'Why are we doing this? This is crazy.' At the most recent workshop, that was all gone. Everyone is so proud of what they have done."


What does CBME mean to you?

[illustration of a resident]Resident

  • Flexibility
  • Individualized learning
  • Enhanced assessment
  • Preparedness for practice

[illustration of a patient]Patient

  • Clinicians focused on patient-centred care
  • Ability to contribute to resident assessment
  • Greater physician accountability

 

[illustration of a faculty member]Faculty

  • Real-time assessments
  • Learner-driven
  • Well-defined learning outcomes
  • Focus on observable competencies

[illustration of society members]Society

  • Fulfills medicine's societal contract to serve patients and communities
  • Focus on skills such as professionalism, communication, and health advocacy
  • Tightens gaps among medical education, health-care delivery, and societal health needs

Better training, better care

There could have been technical issues.

There might have been deeper philosophical issues, or concerns from the Royal College. Most probably, there were going to be issues in getting 100 staff and faculty on board with this new system and its ambitious timeline.

So, Richard Reznick, Dean of the Faculty of Health Sciences, and the other CBME leads worked tirelessly to convince them of the importance of competency-based medical education. Dr. Reznick even gave out his personal home phone number to the entire school so they could call him if they had issues following the launch.

"The phone hasn't rung once," he says.

Even the residents embraced the change, despite being a little unsure as to what they were signing themselves up for. Damon Dagnone, the faculty lead for CBME within the School of Medicine, says the biggest and most pleasant surprise for him has been how CBME has been embraced by the new residents. He says they have been "quite involved" and "excited about the investment into what we feel are already exceptional programs."

The idea of competency-based learning in medicine has been floating around for a number of years. When the Royal College announced its Competence by Design program and the five-year timeline, Dr. Reznick was excited – yet he believed a nimble group like the Queen's School of Medicine could make the change sooner by working as 29 united programs. The school had some prior experience with CBME, as the Department of Family Medicine deployed a competencybased curriculum in 2009.

"We wanted to prove the· principle that this can be done in a scaled-up way, With central leadership and a systems-based model that empowers each program to work together and support each other," explains Dr. Reznick. "We pooled our resources and harnessed the collective power of an excited and charged community of scholars. Now, with CBME setting our program apart from the other medical schools in Canada, our faculty are moving from the audience to the podium – they are the leaders and the innovators."

Still, with plenty of important preparatory work completed, Dr. Dagnone is quick to note that the School has "plenty of race left to run."

"July was really the starting line for us," he says. "Moving forward, we have a number of years of implementation as our first cohort moves through each year of their residency. Our focus for the coming months and years is going to be continuing to gather feedback, engage with our stakeholders, and optimize our IT systems and our curriculum. It's a different pace."

While his home phone remains silent, Dr. Reznick's work phone has been ringing off the hook – with calls from conferences, medical schools, and associations around the world seeking more information. For Dr. Reznick, being the first in North America to institute CBME across an entire school is an exciting accomplishment that builds n what he sees as the mission of all medical educators – "to ensure the next generation of doctors is more skilled than the previous generation."

That enduring focus on constantly advancing new ways of training is part of the School of Medicine's strategic plan, and it shines through in all of its work. "During our last accreditation process, the Royal College and the College of Family Physicians of Canada declared that 'education is not just an add-on, it is in the air that is breathed by the faculty at Queen's,"' says Dr. Dagnone. "They praised the dedication of our program directors and stated that they were 'blown away' by our remarkable culture of education. They realized something that our faculty, learners, and alumni already know: that the School of Medicine is a special place."

[cover graphic of Queen's Alumni Review, issue 4-2017]