By: Karen \’Pinky\’ Schultz
Competency-based medical education (CBME) has been deliberately designed to train learners to provide safe competent care to meet patient and societal needs.1,2 Operationalizing CBME for learners has necessitated a multi-pronged approach, including articulating desired competencies for that safe competent care, planning curriculum and assessment to support and assess those competencies, and tying that assessment to individualized learning plans to optimize every learner’s development.
CBME requires additional or augmented competencies of our faculty. Are we as deliberate in developing faculty’s skills (to meet learner and program needs) as we are those of our learners? Or are we falling short by not providing a similar deliberate and structured approach for faculty to develop the competencies they need to contribute optimally to CBME? Such an approach could be thought of as competency-based faculty development (CBFD).
To be sure, there are some excellent examples of comprehensive faculty development (FD) programs3 but these are not universal. For institutions and/or countries where comprehensive FD does not exist, is it time to institute just such a systematic approach?
If so, what might such a system look like? Falling back on the organizational framework of CBME, the first step would be articulating an agreed upon set of CBME-relevant preceptor competencies. Some national frameworks do outline preceptor roles, some of which drill down to the level of competencies.4-6 These would be a good start. What is not present at this point are widely held benchmarks of expected standards of performance for each educational competency. These would be a necessary addition in order to map out a developmental path for educators.
The next step would be a deliberate sequenced holistic curriculum to build not only competencies but professional identity as clinician-educators. Some competencies would need to be built up iteratively, others would be stand alone. Some would be more relevant at particular developmental stages in an educator’s career. Unlike residents with an end-goal of transition into independent practice, providing a strong motivation to engage in education, there can be a problem in some settings of getting faculty “in the door” to participate in FD. Faculty are often busy clinicians with patient needs always being a first priority. Some are not intrinsically motivated. Attention to motivators, both intrinsic and extrinsic (e.g. CME credits, annual performance reviews) and then making it as easy to participate in FD as possible (e.g. multi-modal, synchronous and asynchronous delivery) should help open that door to participation. One silver lining of the pandemic has been the development of many online, in some cases interactive, platforms. This opens up the possibility of new or improved multi-modal, as well as cross-institutional sessions, and is helpful for sharing resources and creating communities of practice.
CBME has highlighted the value of low stakes assessment for learning, that opportunity to consider behaviourally specific supportive feedback that reinforces and/or corrects actions to guide learners to their individualized next zone of proximal development (ZPD). Faculty rarely receive this—which is such a missed opportunity to optimize faculty development. However, this third step would likely be the most difficult part of CBFD to implement. It would require a developmental map to end-goals, those benchmarks mentioned above. It would require the opportunity for guided/supported self-reflection, ideally from a coach. A coach could be a judiciously used resource, within a program of assessment, with other self-guided reflective exercises comparing personal performance against accepted standards (e.g. timeliness of feedback to learners, quality of written narrative). It would also require faculty openness to such feedback, which would likely require a mind-set shift. For many faculty, who have grown up in settings where all assessment was high stakes, being scrutinized and given feedback can feel uncomfortable.
The fourth step would be that of tying the interpretation of personal performance data, using the map provided by benchmarks, to create an individualized learning plan to guide each faculty into their ZPD. This would also require creating and/or matching up resources to those next steps outlined in the learning plan – as without those resources, highlighting a developmental need without a way to fill it in would quickly disenfranchise people. It would also mean thinking of FD using the added fourth dimension of time, i.e. development to competency and beyond is a step-wise process, not a one and done.
None of this comes without cost however. Within an institution, creating just such a deliberate planned curriculum requires a person or persons with the role, expertise and resources to do this. Institutions would need to support the collection and compilation of faculty assessment data (often easiest, if not cheapest, with an electronic platform), time to interpret the data and motivation to use that data for ongoing development. Safety around data access, particularly if such data might be tied to higher stakes decisions of career advancement, would need to be built in. Coaches are a known way to help scaffold reflection, a new role that itself would require development and time. At a broader systems level, the need for benchmarks is a keystone—how will these be developed and/or widely taken up? Thinking of faculty development curriculum, sharing resources makes sense. Who will curate and maintain repositories of curriculum resources tied to competencies and stages? Can accreditation standards be leveraged to provide the motivation for institutions to carry out their roles in supporting CBFD? Yes, robust CBFD would come with costs. But will we realize the benefits of CBME without competent faculty, supported by CBFD? Can we afford not to?
With thanks to colleagues Drs. Cheri Bethune, Klodiana Kolomitro and Sudha Koppula for their insights and the interesting conversations about this topic
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ABOUT THE AUTHOR: Karen ‘Pinky’ Schultz BSc, MD, CCFP is Associate Dean, Postgraduate Medical Education, School of Medicine at Queen\’s university.
References
1.Frank JR, LS Snell, O ten Cate, ES Holmboe et al. Competency-based medical education: theory to practice. Med Teach. 2010; 32: 638–645.
2. Van Melle E, JR Frank, ES Holmboe, D Dagnone, D Stockley, J Sherbino; International Competency-based Medical Education Collaborators. A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs. Acad Med. 2019;94(7):1002-1009.
3. Gruppen LD, JT Burkhardt, M Fitzgerald, HM Funnell et al. Competency-based programme design and challenges to implementation. Med Ed. 2016: 50 (5): 532-9.
4. Walsh A, S Koppula, V Antao, C Bethune, C Cameron, T Cavett, et al. Preparing teachers for competency-based medical education: Fundamental teaching activities. Med Teach. 2018; 40(1): 80-85.
5. Academy of Medical Educators. Professional Standards (3rd edn, 2014). Cardiff: Academic of Medical Educators (2014)
6. Srinivasan M, S-T T Li, FJ Meyers, DD Pratt, JB Collins, C Braddock et al. Teaching as a competency: Competencies for medical educators. Acad Med. 2011; 86 (10): 1211-122.
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