By: Kelly Caverzagie (@KCaverzagie)
In contemplating the decades-long, worldwide journey towards Competency Based Medical Education (CBME), I am struck by our seeming inability to make considerable progress on a large scale. The reasons for this are likely multifactorial and reflect a myriad of complex issues ranging from administrative, logistical, conceptual,1 regulatory, cultural, and reasons related to integration,2,3 or simply a reliance on old habits and rites of passage that stand in the way of progress (no reference, only my opinion!). I believe there to be another, often subtle, yet more pragmatic, and likely more daunting barrier, that is limiting our CBME progression – the reality that our “frontline” medical educators, those whose programs/institutions aren’t innovating in this space, also aren’t a part of the conversation.
Medical education is hard. Very hard. And complex. If you are reading this post, you know this already. We literally have rules and regulations to clarify our rules and regulations. Our finances, and those of our clinical environments, are under constant pressure in a way that squeezes the educational mission. And our cultures (i.e., medicine AND education) promote the idea that failure is not an option. Adding to the strain is the constant push to optimize safety and eliminate error, which, while necessary and important, precludes one of the most basic tenets of education itself – learning from failure. To the frontline medical educator (e.g., program director, core faculty member, course director) and the learners they care for, the stakes of everyday medical education (i.e., getting through the day and staying on track towards graduation), let alone one focused on competence demonstrated, can be overwhelming.
In our collaborative conversations and work, we (including yours truly) like to focus on the academic nature of competency-based training. For example, we have established complex and competing frameworks, we fawn over large data sets and how they are created/accessed and literally have years-long arguments about the definition of a word. While this work is absolutely, 100% critical to the science of what we do, and what we strive to do, it also misses the mark with the frontline medical educator. Our conversations, and our end products, are not approachable to most of these colleagues. This is not because we are elite, or spiteful, of our frontline colleagues. Instead, I worry that we at times forget about the overwhelming complexity of medicine and medical education and thus work to design a perfect CBME system, instead of one that is “good enough”.
Over the past decade or so, I’ve been fortunate to establish many relationships with colleagues from across the United States who we would all consider to be champions of medical education. Many of these individuals are currently, or previously have been, in positions of leadership within the universe of medical education. Yet, many of them are not only not conversant about our CBME transitions, but they also don’t have the faintest idea about how to move it forward at their program or institution.
With this context, is it any wonder why we haven’t been able to realize the promise of CBME4?
To address this apparent disconnect, I challenge us to consider how to better engage the frontline medical educator and construct models that work for everyone, not just the highly resourced pockets in which innovation tends to occur. How can we make CBME approachable for those who don’t live and breathe this work?
Most are likely familiar with the decades old collection of the “Dummies” self-help books5 that make learning almost anything fun and approachable. Do we need to develop a “CBME for Dummies” self-help book that facilitates implementation of CBME for frontline medical educators. We have produced extensive literature, but is that intended for us or for our colleagues on the frontlines?
Disclaimer: Please know that I am not labeling program directors, core faculty or course directors as “Dummies.” Instead, I’m arguing for a tried-and-true approach to making complex things easier to understand!
To get us started with this conversation, I offer some reflective questions to ponder:
- What makes CBME fun? More appropriately, what will make CBME fun for those that don’t live and breathe it like we do?
- What is the critical next small step to promote our ongoing transformation? What role do frontline medical educators play in taking that small step?
- In CBME, what needs to be ‘perfect’? And what needs to be ‘good enough’?
I know, I know. Regarding the last question, I hear you whispering to yourself, “Do we really want to settle for ‘good enough’?”
My answer is an emphatic, “Yes!”
At least for now.
Hear me out. I strongly argue that for the poorly resourced and pandemically-tired program director, a small step towards ‘good enough’ is a thousand times better at helping our global movement towards CBME. If we are to succeed in the transformation we seek, we need EVERYONE to take that small step forward, not just us “CBME-o-philes” that look to advance this work by leaps and bounds. Stated more bluntly, appreciating, and supporting a collective step towards ‘good enough’ is exactly what our international community needs if we are to achieve our goals.
That is not to say that we stop there – or settle for average. Of course, we MUST continue to scientifically advance the exceptional work our collaborative has stimulated and led over the years. That goes without saying. But doing so in isolation, and without our frontline everyday medical educators, will be counterproductive to the cause.
It’s time we talk to the “Dummies.”
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About the author: Kelly Caverzagie, MD, is a professor in the University of Nebraska Medical Center Department of Internal Medicine, and physician at Nebraska Medicine, He is also UNMC associate dean for educational strategy and vice president for education at Nebraska Medicine. in 2020, he was selected to the Accreditation Council for Medical Education board of directors.
References
1.Hawkins RE, Welcher CM, Holmboe ES, et al. Implementation of competency-based medical education: are we addressing the concerns and challenges? Med Educ. 2015;49(11):1086-1102. doi:10.1111/medu.12831
2. Caverzagie KJ, Nousiainen MT, Ferguson PC, et al. Overarching challenges to the implementation of competency-based medical education. Med Teach. 2017;39(6):588-593. doi:10.1080/0142159X.2017.1315075
3. Nousiainen M, Scheele F, Hamstra SJ, Caverzagie K. What can regulatory bodies do to help implement competency-based medical education? Med Teach. 2020;42(12):1369-1373. doi:10.1080/0142159X.2020.1809640.
Holmboe ES. Realizing the promise of competency-based medical education. Acad Med. 2015;90(4):411-413. doi:10.1097/ACM.0000000000000515
5. https://www.dummies.com/about-for-dummies/ Accessed March 30, 2022.
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