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The objective of CBD is Patient-Centeredness

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The objective of CBD is Patient-Centeredness

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The objective of CBD is to ensure physicians graduate with the competencies required to meet local health needs.

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By: Dan Schumacher (@DrDanSchumacher)

I have noticed that many people, even those responsible for aspects of competency-based medical education (CBME) implementation and maintenance, have trouble succinctly defining CBME. My experiences were confirmed in a recent well-done paper by Sherbino and colleagues, who described tensions in describing CBME among key Canadian opinion leaders.¹

I only need two words to define CBME - patient-focused and learner-centered. For me, every important tenet of CBME maps to one of these two words. As I survey CBME programs around the world, I think most people believe CBME is a learner-centered approach to medical education, even if they do not explicitly use that word to define CBME. However, there seems to be more heterogeneity about whether people believe CBME is a patient-focused approach to medical education. This perplexes me. In this blog, I will explore both components of my definition of CBME to detail why I believe both pieces are foundational to what CBME seeks to achieve.

Patient-Focused

As detailed eloquently in a landmark piece in Lancet2, the design of traditional structure- and process-based medical education begins with defining a curriculum. While it is hoped that this curriculum will prepare trainees to meet the needs of patients, that is not guaranteed. Rather, the curriculum often bends to the interests and desires of those creating it and is prone to, as Stephen Abrahamson quipped in 1978, "diseases" that include ossification (unwillingness to change the curriculum), hypertrophy (adding more and more to the curriculum), and carcinoma (uncontrolled growth of part of the curriculum). Once a curriculum is defined, the traditional approach to medical education defines educational objectives for the curriculum and then assesses learners on how how well those objectives are met in their learning. The patient and what they need is included in this approach in one of only two ways: 1) the curriculum developers ensure that, or 2) happenstance.

CBME turns this model on its head, starting with the end in mind and defining the training/educational outcomes necessary to provide the care that populations of patients need. With CBME, what patients need comes first. From there, requisite competencies and outcomes to meet those needs are defined. Only then are curricula aimed at developing those competencies and ensuring those outcomes developed. In turn, assessment efforts seek to ensure those competencies and outcomes are achieved. Note that assessment is just part of CBME as I describe it here. Too often, CBME is thought of solely as a new approach to assessment. It is not. It is a new approach to medical education entirely. CBME requires a fresh look at curricula as much as assessment efforts.

Learner-Center

Learner-centeredness is a more widely recognized characteristic of CBME. This component of my CBME definition was beautifully detailed in a landmark 2002 article by Carraccio and colleagues.4 In this article, the authors offer several comparisons of structure- and process-based education (traditional approach) and CBME, highlighting the role of the learner. Some of the comparisons they make include:

Driving force of the curriculum: In a traditional approach, content (or knowledge application) is most important for a learner to demonstrate. However, in CBME outcome (or knowledge application) is prioritized.

Driving force for the learning process: The teacher is the driver in a traditional approach; whereas, the learner is in the driver's seat in CBME.

Responsibility for the content: In a traditional approach, the teacher has responsibility for the content. As noted above, this can lead to their interests dominating the curriculum more than they should. In CBME, teachers and trainees share the responsibility for what is learned. Trainees should be given agency, choice, and autonomy in what and how they learn to the extent possible.

Focus of assessment: In a traditional approach, norm-referencing is the focus. Learners are compared to one another to determine who is better and who is not as good. In CBME, criterion-referencing is the focus. Given that the goal is to ensure learners achieve the outcomes needed to provide the care that patients need, everyone could achieve that outcome, no one could achieve that outcome, or any number of individuals between none and all could achieve that outcome. Again, CBME is patient-focused. The goal is to ensure that everyone entrusted to provide unsupervised care is capable of doing so. Criterion referencing should shift focus from competition between learners to collaboration where "best" is defined as the goal of a master adaptive learner developing themselves to be their personal best rather than comparing themselves to others and trying to be #1 on a list where everyone else follows them.

Timing of assessment: In a traditional approach, summative assessment aimed at making overall judgments about performance is the primary focus. While CBME employs summative assessment, it places a primary focus on formative assessment that helps learners understand where they are in their development and help them take next steps.

Patient-focused and learner-centered. The definition of CBME is as simple as two words - albeit two words that pack a lot of details about the foundation and design of CBME. What is more important than learners and patients in medical education? I would argue nothing. This is why I believe CBME is our best path forward for designing our education efforts.

About the author: Daniel Schumacher, MD, PhD, MEd is Director of the Education Research Unit at Cincinnati Children's Hospital Medical Center and a tenured associate professor in the University of Cincinnati's Department of Pediatrics.

References:

1.Sherbino J, Regehr G, Dore K, Ginsburg S. Tensions in describing competency-based medical education: a study of Canadian key opinion leaders. Adv Health Sci Educ Theory Pract. 2021;26(4):1277-1289.

2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. Dec 4 2010;376(9756):1923-58.

3. Abrahamson S. Diseases of the Curriculum. Academic Medicine. 1978;53(12):951-957.

4. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting Paradigms: From Flexner to Competencies. Academic Medicine. 2002;77(5):361-7.

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

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By: Dan Schumacher (@DrDanSchumacher) I have noticed that many people, even those responsible for aspects of competency-based medical education (CBME) implementation and maintenance, have trouble succinctly defining CBME. My experiences were confirmed in a recent well-done paper by Sherbino and colleagues, who described tensions in describing CBME among key Canadian opinion leaders.1 I only need...

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No Matter how well we design our Med Ed, the ultimate goal is a positive impact on the health of the population and improved patient out-comes

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No Matter how well we design our Med Ed, the ultimate goal is a positive impact on the health of the population and improved patient out-comes

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Patient-reported outcomes and patient based outcomes Must be considered in assessing the impact of education programmes, especially at more advanced levels of training.

Dauphinee. (2012). Educators must consider patient outcomes when assessing the impact of clinical training. Medical Education, 46(1), 13–20. https://doi.org/10.1111/j.1365-2923.2011.04144.x

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patient outcome to be considered in evaluating Training

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Collaboration, Community of practice, and Stakeholder commitment.
New policy development, creation of learner ownership, and an increase in the output of scholarly activity involving CBME

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Sargeant, Wong, B. M., & Campbell, C. M. (2018). CPD of the future: a partnership between quality improvement and competency‐based education. Medical Education, 52(1), 125–135. https://doi.org/10.1111/medu.13407
Dalhousie University, UoT

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1. CBME trained physicians are younger and have less experienced than as compared to non-CBME trained physicians.
2. I being part of CBME development, implementation and evaluation process as a faculty member at CoM , am cognizant of my own bias in longing to see CBME as a successful system.
3?Natural Generalizability.: The study is planed in Saskatoon/SK where the peculiar study conditions might be different than rest of the (urban and rural Canada) and thus the study findings can be difficult to shift to circumstances that are not similar to that of Saskatoon.

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1. If synchronized with the audit and improvement in CBME (at all 3 levels) this project could become a major quality improvement initiative in fine tuning the design and delivery of CBME.

'' : Deliberately pairing evaluation alongside change is an important activity and, when accomplished, yields valuable information from the experiences of those implementing and experiencing a program. Evaluation and the development of an updated program theory facilitate the introduction of new changes and theories that build on these findings, which also supports the desired goal of contributing toward cumulative science rather than “reinventing the wheel.”

Hamza, Ross, S., & Oandasan, I. (2020). Process and outcome evaluation of a CBME intervention guided by program theory. Journal of Evaluation in Clinical Practice, 26(4), 1096–1104. https://doi.org/10.1111/jep.13344

UoCalgary

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Description of Methodologies, Study design and Rationale to choose ID.

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Description of Methodologies, Study design and Rationale to choose ID.

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Philosophical Underpinning/World view: Pragmatism (Problem oriented; Pluralistic; Patient oriented; Practical Solutions)
Ontology: Shared Realities/Multiple Realities
Epistemology: Medicine. Medical Education (Experiential Learning)
Methodology: Interpretive Description

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Patients will serve as the main data source of this study.
Patient groups will be divided as follows:
- 10-15 patients treated by physicians trained by CBME
- 10-15 patients treated by physicians not trained by CBME

A brief survey will be handed over to each interviewee at the end of the interview  to collect socio-demographic data i.e. gender, age range, income range, social class/neighborhood of residence, Ethnicity, and Education.

* Participants will have a complete freedom to withdraw from the interviews/study at any time without providing any reasons. This will be made explicit in the participant's consent form.
* On survey, a choice of 'prefer not to respond' will be provided with each question.

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Ethics Approval by Institutional Research Ethics Board, USASK

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Ethics Approval by Institutional Research Ethics Board, USASK

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Ethics approval will be sought by the Institutional Research Ethics Board (IRBB), University of Saskatchewan

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How Do I Create Behavioural Ethics Participant Materials and Consent Forms?

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Study participants will be recruited in the following ways:    - In partnership with Saskatchewan Centre for Patient Oriented Research (SCPOR)

Posters, both, physical and electronic will be posted on the USASK Bulletin and USASK PAWS announcements using USASK poster template.

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Patient-oriented research (POR) occurs when multi-disciplinary research teams engage patients, as well as their caregivers and families, as partners in the research process. POR focuses on patient-identified priorities that lead to improved patient outcomes in health care.

Patient-oriented research teams are multi-disciplinary. The goal is to include Patient Partners, families, clinicians, researchers and policy-makers on research teams to work together and identify research topics, complete the research and then use the results of that research to improve patient care and the health system.

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Patient-oriented research (POR) occurs when multi-disciplinary research teams engage patients, as well as their caregivers and families, as partners in the research process. POR focuses on patient-identified priorities that lead to improved patient outcomes in health care. Patient-oriented research teams are multi-disciplinary.

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Data Collection Instruments:
Patient Interviews.
Participants will be recruited from patients visiting family physicians and specialists be filled (Target n=30 (15 managed by physicians trained by CBME VS 15 managed by the physicians that are not trained by CBME Med Ed). The gathered information shall be used to identify emerging themes.

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Data Analysis - Process and synthesis of result.

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Data Analysis - Process and synthesis of result.

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Constant Comparative Analysis will distill the themes

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Human is the main research instrument for qualitative study and analysis, however sophisticated software such as NVIVO or Atlas Ti will be utilized for data entry, management, manipulation/exploration, theme categorization and visuals generation , etc.
Transcription of the interview scripts will be done in SSRL.

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Comprised of seven research laboratories (Experimental Decision Laboratory; EEG Hyperscanning Laboratory; Qualitative Research Laboratory; Social Network Laboratory; Spatial Analysis For Innovation in Health Research Laboratory; Survey and Group Analysis Laboratory; and Video Therapy Analysis Laboratory), the SSRL and its component laboratories are available on a fee-for-service model to community partners outside of the university setting. With over 600 m 2 of available research space, and more than 100 computers with specialized software for data collection, analysis and reporting, the SSRL provides on- and off-campus researchers with access to the most sophisticated social research tools and techniques available.

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Social Sciences Research Laboratories (SSRL)

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Comprised of seven research laboratories (Experimental Decision Laboratory; EEG Hyperscanning Laboratory; Qualitative Research Laboratory; Social Network Laboratory; Spatial Analysis For Innovation in Health Research Laboratory; Survey and Group Analysis Laboratory; and Video Therapy Analysis Laboratory), the SSRL and its component laboratories are available on a fee-for-service model to community partners outside of the university setting.

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What is the perception of quality of care in the patients treated by physicians trained by CBME vs the perception of quality of care in patients treated by physicians who were trained by Non-CBME system of medical education ?

Dietl, Charles A., MD, & Russell, John C., MD. (2016). Effect of Process Changes in Surgical Training on Quantitative Outcomes From Surgery Residency Programs. Journal of Surgical Education, 73(5), 807–818. https://doi.org/10.1016/j.jsurg.2016.03.015

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Effect of Process Changes in SurgicalPatientOutcome

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Reflexivity
Audit Trail
Constant Comparative Analysis
Member checking
Inclusion of a diverse group of participants