By: Karen Hauer
Competency based medical education (CBME) represents a transformation in the design of learning and assessment activities to emphasize desired outcomes of training. CBME shifts focus from teachers (what they teach and how they prefer to assess) to learners (what they learn and how they demonstrate their learning). Through incorporation of frequent feedback and individualization of learning experiences and learner progress, CBME also adheres to defined criteria for advancement and completion of training. As health professions education programs increasingly adopt CBME, many have simultaneously diversified their learner populations to meet the needs of the diverse patient populations they will serve. Hence, attention to the importance of equity in assessment is paramount.1 Well-designed CBME with commitment to equitable assessment can promote successful learning and achievement for diverse learners.
Traditional approaches to assessment in medical education have yielded group differences in performance that disadvantage learners from minoritized backgrounds. For example, value placed on high stakes, summative assessments of medical knowledge rewards high scores and metrics. Structural differences in educational opportunities through childhood and college render advantages to learners privileged with access to top schools, tutors, and practice materials. Similarly, assessments of clinical activities that value performance over growth and improvement, or recitation of facts over contributions at patients’ bedsides, advantage learners who enjoyed early access to shadowing or work opportunities in clinical settings. By defining expected outcomes and individualizing learning experiences, CBME can help address these inequities in learner assessment.
How can CBME promote equity in assessment?
CBME emphasizes assessment for learning.
With assessment for learning, the first priority of assessment is to serve the purpose of promoting learners’ development, rather than to rank or sort learners.2 The teacher’s role in assessment for learning is to make expectations (competencies, milestones, EPAs) clear, align teaching with assessment, and adapt teaching and learning in response to individual learners and their learning needs. Thus, the teacher frequently observes each learner and their work, rather than teaching and assessing all learners in exactly the same way. Differences among learners and their knowledge, skills, and perspectives are expected and welcome – hallmarks of an inclusive environment. Teachers work with each learner to identify the gap between the learner’s current performance and where they need to go, and discuss feedback to help them get to the goal.
CBME necessitates collection of multiple sources of evidence.
CBME defines multiple competencies necessary for effective practice, using frameworks such as the Canadian CanMEDS roles or United States Accreditation Council for Graduate Medical Education competencies and milestones. By avoiding over-emphasis of the medical knowledge competency and enhancing value placed on collaboration, improvement, and patient advocacy to address health inequities, CBME recognizes the many and varied contributions of diverse learners.3
CBME engages learners in the assessment process
CBME shifts focus from the teacher toward the learner in the selection and implementation of learning activities. Individualizing learning experiences to a particular learner enables a skillful teacher to demonstrate culturally sensitive approaches and build relationships with individual learners that are responsive to their backgrounds, learning needs, and goals. Though feedback discussions and learning planning with teachers or coaches, learners can articulate their individual goals and propose strategies and experiences to address them.4
CBME values subjectivity in assessment
Programs of assessment for implementing CBME incorporate multiple low stakes assessment activities, to facilitate collection of multiple data points that can be interpreted to create a well-rounded view of each learner and their progress toward achieving expectations.5 This approach contrasts with the psychometric view of excellence in assessment, defined through reliability and reproducibility, and instead favors expert judgment by groups to compare a learner’s performance to the standard.6 The experts making such judgements will of course bring their own biases to this work; to promote equity, these experts should be selected to represent diverse backgrounds and perspectives, and should undergo training in assessment, implicit bias, and group decision making.
Recommendations to promote equity within CBME
1. Bias: Individual written evaluations of learners may contain language that suggests bias based on race/ethnicity, sexual orientation/gender identity, or other learner characteristics. It is essential to engage all supervisors in training on implicit bias and strategies for equitable assessment along with feedback to individual supervisors whose assessments demonstrate bias.7
2. Involve learners in assessment design and continuous improvement: Assessment in a CBME program should happen with the learner rather than happen to the learner. To avoid a hierarchical approach to assessment, learners can be involved from the beginning in contributing to defining learning outcomes,8 which for CBME are commonly competencies and milestones. CBME makes expectations transparent to learners and teachers. Learners can help answer questions such as: are the program outcomes understandable, inclusive, and free of bias? Do the outcomes suggest that each learner would be prepared to care for diverse patients and populations and promote health equity?
3. Learning environment: To learn and demonstrate competence, a learner must have opportunities to participate and practice skills and discuss and apply feedback. In an equitable learning environment, the learner does not experience microaggressions against learners, patients or team members. Microaggressions are subtle or sometimes blatant comments, behaviors and environmental features that communicate hostility and serve to perpetuate vulnerability, incite fear, and distract from meaningful learning for minoritized learners. Equity and psychological safety exist when each learner feels safe to ask questions and take learning risks without being penalized.9
4. Monitor your data: Analysis of learner performance data to continuously improve program quality is a hallmark of a CBME program. Analysis of learner performance data for equity may demonstrate group differences that favor non-minoritized learners; such differences signal inequity in the design, implementation and interpretation of assessments, or in the learning environment, that must be examined to identify root causes and address them to ensure equity.
CBME can promote equity in assessment to realize our focus on outcomes of training: to prepare physicians and other health care providers of the future to optimize the health of all patients.
References
1. Lucey CR, Hauer KE, Boatright D, Fernandez A. Medical Education’s Wicked Problem: Achieving Equity in Assessment for Medical Learners. Acad Med. 2020;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S98-S108.
2. Wiliam D. What is assessment for learning? | Elsevier Enhanced Reader. Studies in Higher Education. 37:3-14.
3. Teherani A, Perez S, Muller-Juge V, Lupton K, Hauer KE. A Narrative Study of Equity in Clinical Assessment Through the Antideficit Lens. Acad Med. 2020;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S121-S130.
4. Molloy E, Boud D. Seeking a different angle on feedback in clinical education: the learner as seeker, judge and user of performance information. Med Educ. 2013;47(3):227-229.
5. van der Vleuten CPM, Schuwirth LWT, Driessen EW, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34(3):205-214.
6. Hodges B. Assessment in the post-psychometric era: learning to love the subjective and collective. Med Teach. 2013;35(7):564-568.
7. University of California, San Francisco (UCSF) School of Medicine. Equity in Assessment Guidelines and Checklist. https://meded.ucsf.edu/faculty-educators/equity-assessment-guidelines-and-checklist
8. Equity in Assessment. National Institute for Learning Outcomes Assessment (NILOA). Accessed January 25, 2022. https://www.learningoutcomesassessment.org/equity/
9. Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. John Wiley & Sons; 2018.
About the author: Karen Hauer, MD, PhD is Associate Dean for Competency Assessment and Professional Standards and Professor of Medicine at the University of California, San Francisco (UCSF).
The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The Royal College of Physicians and Surgeons of Canada. For more details on our site disclaimers, please see our ‘About’ page
