By: Kim Lomis (@KimLomisMD) and Denyse Richardson (@DrDenyseR)
“Competency Based Medical Education (CBME) is an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies. It deemphasizes time-based training and promises greater accountability, flexibility, and learner centredness.”1. To deliver on these promises, CBME must offer tailored training that promotes each learner’s individual professional development.
CBME presupposes a developmental orientation and an acknowledgement that each learner and practicing clinician pursues a unique path of continual growth in competency. Learners must be active agents in the process who surrender to a level of vulnerability that is not promoted by current systems of medical education. We suggest that coaching – whether in the moment or in a longitudinal manner – is a critical element to implementing CBME with fidelity2.
Coaching, as a methodology for promoting development, is flourishing in many professional domains and as a result, many are reaping the benefits. However, coaching may not always look or feel the same – context is key!! Coaching for development of competence and adaptive expertise in Medical Education –and even more broadly, for all Healthcare Professional Education– differs from traditional teaching, mentoring and advising [See Figure 1]3. One imperative distinction is in the orientation of coaches toward asking over telling. Competency frameworks provide clarity regarding overarching goals for development. A coach supports the learner in contextualizing feedback on performance to understand their individual trajectory of development. Coaching focuses on solutions: leading and guiding, not telling, any learner through a process of reflection, which enables them to identify personalized goals within the larger framework and create individualized pathways for learning. The dyad of individual learner –the coachee– and coach is a critical relationship based in trust that the individuals involved and the educational system value learning and the best interests of the learner as essential to optimizing patient care. But it is important to acknowledge that, even within the context of Medical Education and CBME, coaching isn’t always going to look, feel or be the same, nor is it likely that it should, in order to meet the diversified needs of all learners in medicine.
As part of Canada’s CBME implementation, Competence by Design (CBD), a coaching model is being employed. The CBD coaching model is part of an important philosophical shift in thinking about workplace-based learning and its purpose. This Canadian Coaching model inherently defines two distinct coaching roles – “Coaching in the Moment” and “Coaching over Time” [See Figure 2]. Both coaching roles rely on the use of observed clinical work as opportunities for learning.
Coaching in the Moment is coaching that occurs after a clinical teacher/supervisor observes, directly or indirectly, some form of work done by a learner in a clinical setting. When clinical teachers directly observe the work residents do or gather other data indirectly about the work that is done, these observations provide the opportunity to engage in coaching. Such a coaching conversation allows the learner to glean actionable steps or suggestions for improvement, in the pursuit of optimal performance.
In Canada’s CBD, Coaching in the Moment follows a step-by-step process known as RX-OCR[See Figure 3] Using the RX-OCR process promotes coaching, irrespective of the duration of the clinical learning experience. Observations done as part of Coaching in the Moment are low stakes snapshots of daily work and the coaching provided needs to be a normal part of the learning process to facilitate development toward competent practice. Coaching helps a learner understand what adjustments and modifications will allow them to progress to the next level of capability/proficiency.
Figure 3. RX-OCR, Copyright The Royal College of Physicians and Surgeons of CanadaCoaching in the Moment requires the coach to have the clinical acumen and expertise of the clinical setting. Clinical settings exert time pressures and competing priorities, particularly the delivery of patient care, that often do not allow much inquiry-based coaching. But, Coaching in the Moment still guides the learner to reflect on what was done and how one might improve for the next time. A clinical coach in the moment might demonstrate a skill or technique, enabling the learner to reflect on needed adjustments. In medical learning environments, when acquiring skills and expertise in patient care are paramount, coaching may need to be more directive and less reflective, contrary to longitudinal models of coaching, which are founded upon the coach asking stimulating or reflective questions.
Coaching over Time requires a more longitudinal relationship between a designated coach, not necessarily a clinician, and the resident. This educational partnership spans across varied settings and clinical experiences and is driven by multiple sources of performance evidence. It requires regularly scheduled face-to-face discussions about the resident’s progression. These coaching encounters are informed by observations recorded in the learning portfolio yet can follow the same step-by-step process as Coaching in the Moment, RX-OCR. Performance patterns are identified jointly and learning opportunities are planned accordingly. For an educational alliance to develop and work well, the coachee must feel confident that the coach has the resident’s best learning interests in mind. Coaching over Time fosters informed self-assessment, helping the resident become an independent, competent clinician as well as one that is prepared for a career as a self-regulated learner.
This combination of Coaching in the Moment and Coaching over Time supports two educational constructs critical to CBME – deliberate practice and mastery learning. Ericsson ‘s concept of deliberate practice is founded upon (a) repetitive performance of intended cognitive or psychomotor skills (b) rigorous skills assessment (c) specific informative feedback, including suggestions for improvement and (d) confirmation of better skills performance. Mastery learning implies a higher level of performance than competence alone. The Master Adaptive Learner is one who actively engages in iterative cycles of identifying and pursuing one’s learning needs4. Mastery learning and CBME offer individualization of education to support competence acquisition within formal education programs, such as residency, and training in these models will promote continuous improvement for all physicians for the duration of their whole career. McGaghie et al assert that CBME featuring mastery learning with deliberate practice can lead to better health for individuals and populations5. Coaches serve to accelerate these processes.
Instituting coaching at a programmatic level may be a critical step in creating a culture that supports a growth orientation. Current environments of learning and assessment promote a performance orientation, exerting pressure to conceal one’s learning needs in favour of appearing capable. Even the strongest coaching dyad may not be able to overcome the structural perfectionism in medicine that limits ongoing development and imperils patient safety. Programmatic implementation of coaching signals an institutional acknowledgement of – and investment in – the need for continual improvement for all. This could help shift perceptions of frequent feedback from a threat (more ways to fail) toward an aid in a collective striving for excellence. Given important efforts to better attend to, and increase, the diversity of learners in medicine, cohorts of trained coaches may serve to uncover and mitigate bias in institutional processes of assessment and learning opportunities. Modeling institutional humility is crucial to promoting individual transparency.
The resources required to invest in programmatic coaching are not trivial. The medical education community must collaborate to develop effective and efficient models of coaching. Our current education systems are heavily invested in delivery of content that can be otherwise accessed from a variety of sources; educational institutions should shift investments into observation, feedback and coaching at the individual level. Given that thousands of trainees are preparing to advance in responsibilities this summer in the context of highly individualized disruptions to their education, the medical education community might challenge ourselves to consider the costs of not knowing and responding to the individual developmental needs of each of them.
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About the authors:
Kimberly D. Lomis MD is vice president for Undergraduate Medical Education innovations at the american medical association.
Denyse Richardson BScPT MD FRCPC Med is an Assistant Professor and a Clinician Educator at the University of Toronto in the Department of Medicine, Division of Physiatry.
References:
1. Frank JR et al. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teacher. 2010;32: 631-7
2. Van Melle E et al. A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs. Academic Medicine. 2019;94(7):1002-1009.
3. Hammoud MM, Deiorio NM, Moore M &, and Wolff M. (Eds) Coaching in Medical Education, 1st Edition. 2022. Elsevier Inc.
5. Lomis KD et al. The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education. Medical Teacher., 2021; 43:sup2, S7-S16.
6. McGaghie WC et al. Medical education featuring mastery learning with deliberate practice can lead to better health for individuals and populations. Academic Medicine. 2011;86(11):e8-9.
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