By Jamiu Busari (@JoBusar)
Background
Competency-based medical education (CBME) is an educational approach that aims to prepare physicians for practice by focusing on outcome abilities.1 These abilities or competencies are the products of extensive analysis of societal and patient needs that resulted in developing a medical curriculum that would promote greater accountability, flexibility, and learner-centeredness. The International Competency-Based Medical Education Collaborators (ICBME) are a conglomeration of international medical education experts who explore conceptual issues around CBME and engage in discourse around strategies to improve and innovate curricular content. This initiative responds to society\’s demand for competently trained and goal-oriented physicians, capable of shouldering broad responsibilities and ready to deal with the complexities of being modern physicians, i.e., transformational health care leaders.2,3
The need for CBME
Supported by educational theory, CBME uses physicians\’ explicit abilities (or competencies) to organize medical education. This process is done by defining and effectively integrating essential knowledge, skills, values, and attitudes needed for practice into the curriculum.2 Subsequently, these competencies act as the \”organizing units\” for designing related education programs and assessment strategies.4 So far, most of the advances in CBME have been reported from developed countries in Europe, North America, and Asia. Further, several innovations in CBME have reportedly come from institutions and healthcare systems in these countries, thereby failing to fully reflect the success, challenges, and innovative practices of CBME in non-western contexts. For example, CBME innovations that work in western-based contexts may not be applicable in non-western contexts due to poor educational infrastructure and workforce. Equally, proven low fidelity and effective educational strategies in non-western contexts are unlikely to make their way to the larger (and predominantly Western) CBME academic community. As such, CBME programs in developed countries are, by default, denied access to straightforward, cheaper, and scalable educational strategies from non-western settings. Hence, from a critical point of view, it can be argued that we may be losing out across the board on some of the potential benefits of CBME for trainees, educational institutions, and patients in both contexts.
Medical programs in the Caribbean
Medical education in the Caribbean can be seen as an \”exotic mix\” in terms of the area\’s geography, the differences in the local medical training programs, and the diversity of the islands and their local cultures. In terms of medical education, at least three different curricula frameworks can be identified in the Caribbean region. These include local Caribbean medical curricula, the ACGME Core Competencies, and the CanMEDS Framework.
The University of the West Indies (UWI) is a fully autonomous Caribbean medical institution with a curriculum that awards degrees to students. The UWI began at Mona, Jamaica, as an overseas medical college of the University of London in 1948. It became a regional institution in 1963 with campuses in Jamaica, Trinidad, and Barbados. The UWI has faculties that operate within the governance and policies of their campus and under an established and structured central administration.
The ACGME medical curriculum is another program used predominantly by Offshore Caribbean medical schools (OCMS), which made its entry into the Caribbean in the late 1970s and has grown significantly since then. Many of the OCMS recruit, almost exclusively, U.S. citizens and international students who plan to pursue residency training and licensure in the United States. As of 2012, 63 open Caribbean medical schools were listed in the International Medical Education Directory5. The region\’s third category of medical schools use the CanMEDS framework in their programs and are European teaching hospitals with satellite or affiliate teaching hospitals in the Caribbean6. Essentially, the institutions running these programs are Dutch-based university medical centers in Groningen, Amsterdam, and Maastricht with affiliated teaching hospitals in Curacao, Bonaire, and Aruba.
Experiences from CBME in the (Dutch) Caribbean.
In several countries around the world, large-scale curricular reform in medical education has led to the incorporation of professional roles describing the desired competencies of future physicians. The construct of these desired competencies in the Dutch Caribbean has been based on the CanMEDS Framework.7-9 From a theoretical perspective, the ongoing developments in CBME offer potential new possibilities for undergraduate and postgraduate medical training in the Caribbean.10 As we know, the emphasis of CBME is to provide precise descriptions of (specified) competency outcomes; however, its implementation remains challenging due to continuous modifications in curriculum design, student assessment practices, teacher preparation, and systemic institutional reforms.2 Also, the educational, healthcare, and economic value of CBME in Caribbean communities have been proven, although upscaling the implementation and disseminating the benefits remains a significant challenge.11
Conclusion
As we strive to bring uniformity to the way physicians are being trained through CBME, the challenge for Caribbean medical institutions remain the “if” and “how” CBME can be applied to their programs. This is because of persistent factors, such as, the lack of consistent oversight of educational programs in the region, new offshore medical schools rising rapidly, and the persistent concerns about the quality of medical training in the area.12,13 Furthermore, global health disasters, climate change, and other geopolitical upheavals have exposed existent socioeconomic, racial, and educational inequities and their impact on these communities.
In conclusion, as we continue to engage in the CBME conversation, it is imperative that educational researchers and curriculum developers understand how to promote CBME in a way that it optimally serves institutions with limited resources in the Caribbean and other non-western contexts. We should also rethink how medical education can be designed and implemented in such a way that all nations, both developed and developing, are served equitably and can benefit from the true value of CBME.
References
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2. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-45.
3. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923-58.
4. Albanese M, Mejicano G, Gruppen L. Perspective: Competency-based medical education: a defense against the four horsemen of the medical education apocalypse. Acad Med. 2008;83(12):1132-9.
5. Eckhert NL. Perspective: private schools of the Caribbean: outsourcing medical education. Acad Med. 2010;85(4):622-30.
6. Duits AJ, Kuks JB, Busari JO. Global health education in the Dutch Caribbean: 50 years of a unique Groningen-Curaçao clinical clerkship program. Journal of Global Health Research. 2020;4.
7. Ten Cate O. Medical education in The Netherlands. Med Teach. 2007;29(8):752-7.
8. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542-7.
9. Koeijers JJ, Busari JO, Duits AJ. A case study of the implementation of a competency-based curriculum in a Caribbean teaching hospital. West Indian Med J. 2012;61(7):726-32.
10. Busari JO, Verhagen EA, Muskiet FD, Duits AJ. Implementation of a competency-based residency curriculum: experiences from a resource-limited environment in the Caribbean. Med Teach. 2008;30(9-10):e189-95.
11. Busari JO, Duits AJ. The strategic role of competency based medical education in health care reform: a case report from a small scale, resource limited, Caribbean setting. BMC Res Notes. 2015;8(13):8.
12. van Zanten M, Boulet JR. Medical education in the Caribbean: quantifying the contribution of Caribbean-educated physicians to the primary care workforce in the United States. Acad Med. 2013;88(2):276-81.
13. Busari OJ, Vervoort M, Hermans SM, Blom JR. Medical education in the new millennium–a Caribbean perspective. Med Educ. 2001;35(7):703-6.
About the author: Jamiu O. Busari, MBChB MD PhD MHPE CCPE, is an Associate Professor of medical education and researcher at Maastricht University and a pediatrician at the Horacio E. Oduber Hospital in Aruba, where he founded and leads the Aruba Childhood Obesity Prevention Program.
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