By: Holly Caretta-Weyer (@holly_cw)
A significant promise of competency-based medical education (CBME) is that medical education ought to be a continuum along which trainees progress based upon the development of competence and granting of further independence. However, it clearly is not. I often find myself lying awake at night asking myself, why is that and what can we do to address it?
Root Cause of Discontinuity
First, why has CBME not created a true, seamless continuum of medical education from entry into training until retirement from the profession? If approaching this as a root cause analysis, components that might be proposed would range from the absence of a uniform assessment framework to the lack of transparent communication between different phases to the competitive nature of the residency selection process. Each of these component example “arms” of the recognizable fishbone diagram leading to the ultimate root cause are derived from a lack of a shared educational vision and coproduction of outcomes and priorities across medical school, postgraduate training, and into continuing professional development. These mismatched priorities and foci between stakeholders within each phase of training ultimately prevent the actualization of a true continuum.
Many may push back and say that, at face value, it seems obvious that medical schools, postgraduate training programs, and certifying bodies retain a shared aim in training and certifying physicians to care for individual patients and society. While inherently true, there are alternative priorities and outcomes at each phase of training and practice as well as logistical barriers to a continuum. These are illustrated by examining some of the “signs and symptoms” created at the key transition points that present the greatest discontinuity felt by physicians in training. We will tackle one example here.
Impact of Discontinuity
The transition from medical school to postgraduate specialty training is a time of significant discontinuity, felt by students, faculty, program directors, and many other stakeholders. Key evidence of this discontinuity is demonstrated by a lack of a meaningful and transparent learner handover from medical schools to residency programs. A learner handover requires information about each student be transmitted from one phase of training to the next.1 This would include assessment data encompassing competencies achieved and areas for improvement, student priorities for personal and professional development, and progress in domains important to the specialty the student has chosen to enter.
However, the mismatch in priorities between medical schools and postgraduate training programs often leads to two key, potentially unintended, outcomes: 1) opacification of growth-oriented data to protect students in the residency selection process due to fear of programs using that information to select against students; and 2) lack of transparency around assessment as each program of assessment is often individual to the school, lacks a unifying framework across the transition, and the data is not easily transferable to the receiving residency program. This leaves postgraduate programs to begin anew with each entering trainee instead of continuing progress made in medical school and tailoring training to each individual resident from the start.
Paving a Way for Continuity
This disconnect in priorities and its resultant disruption in what is intended under CBME to be a continuum may seem insurmountable. However, there is a model that may provide a meaningful way forward. Coproduction has been posited in the literature to address the mutual construction of learning outcomes between learner and teacher as well as the partnership in producing healthcare outcomes between physician and patient.2,3 Why not then use this approach as a way forward for developing a true continuum of medical education by creating a systems-level coproduction model for medical schools, postgraduate training programs, and certification bodies? Stakeholders responsible for each phase of the continuum have key knowledge of their own goals and priorities, assets and susceptibilities, and context and resources. By bringing these stakeholders together and creating roles for individuals to specifically and meaningfully span the continuum to facilitate this model of coproduction, this allows for the developing and execution of shared outcomes across each phase of medical education.
Potential examples of systems-level coproduction include:
Unified Assessment Framework: Designing a consensus-driven, integrated, and progressive assessment framework accompanied by transparency around assessment data across the continuum would aid in the continued developmental growth of learners from initial training through unsupervised practice. This would replace or intercalate siloed, mismatched assessment frameworks unique to each phase of training.
Longitudinal Learner Portfolios: Key to allowing for coproduction between learners and other stakeholders is the development of an electronic repository for assessment data, competency achievement, personal and professional development goals, artifacts, learning plans, and other items. This would provide an avenue for trainees and coaches to coproduce learning, individualize opportunities, and serve as a database from which to demonstrate achievements and scholarly projects, track progress for summative entrustment, and provide data to support initial and continued certification.
Revised Residency Selection Process: The residency selection process is a key barrier to the continuum. Coproduced outcomes of medical training as a whole, training in a given specialty, and individual programs are key to driving the revision of selection criteria, subsequently allowing for holistic review aligned with a competency-based system that aligns individual and program-level aims with societal needs.
Learner Handover: As discussed above, a comprehensive and transparent learner handover including growth-oriented assessment data is key to continued development along the continuum. This would be greatly enabled by the systems-level coproduction of a unified and integrated assessment framework and longitudinal learner portfolios.
Organizational Policy Changes: A final key example is higher order policy changes around barriers such as how education is funded and how initial and continued certification is performed. Organizational stakeholders have the ability to coproduce creative solutions that allow for a more seamless continuum with funding models that afford space for time variable progression and certification based on measures of competence derived from a unified assessment framework.
These examples are not exhaustive but provide an initial roadmap for potential ways forward. Only by meaningful coproduction at the highest levels across organizational, institutional, and programmatic stakeholders and the development of novel roles that span silos will be we able to actualize the continuum that CBME promises.
About the author: Holly Caretta-Weyer, MD, MHPE, is the Associate Residency Program Director and Director of Evaluation and Assessment for the Stanford University Emergency Medicine Residency Program as well as EPA/CBME Implementation Lead at the Stanford University School of Medicine.
References:
1.Morgan HK, Mejicano GC, Skochelak S, et al. A responsible educational handover: Improving communication to improve learning. Acad Med. 2020 Feb;95(2):194–199.
2. Holmboe ES. Work-based assessment and co-production in postgraduate medical training. GMS J Med Educ. 2017 Nov;34(5):Doc58.
3. Englander R, Holmboe E, Batalden P, et al. Coproducing health professions education: A prerequisite to coproducing health care services? Acad Med. 2020 July;95(7):1006-1013.
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