The implementation of CBME into postgraduate medical education programs is a complex process. One key element in implementation relates to the role regulatory bodies play – they can either help or hinder attempts at introducing new CBME-based curricula, assessment, and feedback practices. This blog post relates to a paper that my colleagues and I recently published on the topic1 – I think it’s quite relevant considering the continued push many programs have in trying to implement CBME into their training programs.
Regulatory bodies can be defined as those authoritative bodies responsible for ensuring program quality (e.g., accreditors), granting legal access to practice (e.g., licensing/physician registration bodies), and granting operational access to practice (e.g., institutional credentialing bodies, medical specialty boards). Multiple regulatory bodies exist at several levels (regional and national) to ensure that their members practice at an accepted standard of proficiency. In general, the goals of these regulatory bodies are to ensure that common standards of training occur in graduate medical education programs, that practicing physicians demonstrate adherence to standards of patient care, and that physicians who are not practicing with the accepted standard of care are identified, rehabilitated and possibly removed from practice. Despite these goals, regulatory bodies often exist in complex systems, operating in independent silos due to the fact that they focus on regulating certain aspects of a medical professional’s practice and not others. In addition, the policies and procedures used by these bodies to govern were both developed and applied in curricular models of medical education that largely preceded CBME. As such, even though some regulatory bodies may support the implementation of CBME in their jurisdictions, they may not be able to facilitate the ease of its implementation.
Successful implementation of CBME requires that the structural changes necessary to deliver CBME-based curricula and methods of assessment must be properly organized, the processes of evaluation must be modified, and the culture of education must be changed in order to foster acceptance of the new paradigm.2 Specific changes that must occur in the current medical education system to allow for change include the integration of education re-design efforts, an agreement on defining the relevant educational outcomes, mutual accountability amongst educators, trainees, and health care administrators and the assurance that all stakeholders responsible for regulation in medical education be aligned and supportive in ensuring that this change occurs smoothly and effectively.
Previous work looking at implementation3,4,5 and the introduction of novel curricula in medical education6,7,8 has shown that many specific elements must be satisfied for effective change to occur. Regulatory bodies must demonstrate strong and stable leadership that approves and supports the change. This must also be present at the local (training program) level as well, where stakeholders (i.e. faculty, trainees and administrators) must be ready to accept the proposed change and appreciate its relative advantages. Regulatory leaders must incentivize academic medical centers, learning health systems and other learning environments to support CBME with specific goals and timetables established. Clear and specific methods for achieving the goals must be outlined and understood by all of those involved in the change. Effective communication must occur at all levels to ensure that concerns are addressed and successes shared. Structures and processes for stakeholders to learn, develop, co-create, and promote innovation must be developed and encouraged. Failsafe, easy-to-use modes of communication must exist and resources relevant to the new system, such as electronic servers that house learning curricula and assessment tools, must be ready for use.
In jurisdictions where CBME has been successfully implemented, such as the Netherlands, Canada and the USA, regulatory bodies have been found to play a positive role in implementing CBME in three ways.1 First, they can assist in the restructuring of accreditation and regulatory criteria along CBME principles. Second, they can work together (in jurisdictions where multiple regulatory bodies play a role in physician regulation) in a coordinated fashion to ensure the alignment of regulatory measures through the training and practice phases of a physician’s career using a CBME lens. And third, they can allow physicians and training programs to adapt the principles of CBME to their individual context.
If CBME is to be the new paradigm for medical education, we must collectively identify how the barriers to successful implementation can be overcome. Accreditation and regulatory criteria must align with CBME principles (as is happening in the US where initiatives such as the Milestones and CLER are helping to move towards an outcomes-based system of accreditation).9 Regulatory bodies must also work together in a coordinated fashion to ensure alignment of vital regulatory measures throughout the training and practice continuum of a physician. At the same time, these regulatory bodies must allow for, if not incentivize, individuals and programs to adapt CBME to meet their local environments and innovate in order to meet the needs of the communities that they serve.
There is no doubt that systems of professional regulation are key players in permitting and supporting the transition to CBME — they can either help or hinder the process. What challenges do you have in your efforts to move to CBME? What advice do you have for others facing the same issues?
References
1.Nousiainen M, Scheele F, Hamstra S, Caverzagie K. What can regulatory bodies do to help implement competency-based medical education? Med Teach. 2020 Aug 27:1-5.
2. Caverzagie KJ, Nousiainen MT, Ferguson PC, Ten Cate O, Ross S, Harris KA, Busari J, Bould MD, Bouchard J, Iobst WF, Carraccio C, Frank JR; ICBME Collaborators. Overarching challenges to the implementation of competency-based medical education. Med Teach. 2017 Jun:39(6):588-593.
3. Kotter JP. 2012. Accelerate! Har Bus Rev. 90(11):44-52, 54-58, 149.
4. Rogers EM. 2004. A prospective and retrospective look at the diffusion model. J Health Comm. 9 Suppl 1:13-19.
5. Weggeman M. 2014. Managing Professionals: Don’t!: How to step back to go forward. Amsterdam, the Netherlands: Warden Press.
6. Lesky L, Davis A, Cooke M. 2001. How did we make the Interdisciplinary Generalist Curriculum Project work? National efforts to facilitate success. Acad Med. 76(4 Suppl):S26-30.
7. Afrin LB, Arana GW, Medio FJ, Ybarra YF, Clarke HS Jr. 2006. Improving oversight of the graduate medical education enterprise: one institution’s strategies and tools. Acad Med. 81(5):419-425.
8. Bank L, Jippes M, Leppink J, Scherpbier AJ, den Rooyen C, van Luijk S, Scheele F. 2017. Are they ready? Organizational readiness for change among clinical teaching teams. Adv Med Educ Pract. 14(8):807-815.
9. Institute of Medicine. 2014. Committee on the Governance and Financing of Graduate Medical Education Board of Health Care Services: Graduate Medical Education That Meets the Nation’s Health Needs. Washington, DC: National Academies Press.
About the author: Markku Nousiainen, MD MSc FRCSC is an Associate scientist of Clinical Integrative Biology in the Holland Musculoskeletal Research Program at Sunnybrook Research Institute as well as staff in the
Orthopaedic Surgery staff at the Sunnybrook Health Sciences Centre and
Associate Professor in the Department of Surgery at the University of Toronto\’s Faculty of Medicine.
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