By Carol Aschenbrener, MD, Robert Englander, MD, MPH, and Janet Bull, MPA
We are at a tipping point in competency-based medical education (CBME) — and it’s only taken 40 years since the competency conversation first appeared in the medical literature!In case you were not aboard the CBME train as it left the station, this concept is an integrated framework for education, in which specific behavioral outcomes (competencies) drive both medical school curricula and individual advancement, rather than the current driving forces of time (four years of medical school) and process (clerkships of specific length). We believe that competency-based medical education focuses on what a physician should actually be able to do, as grounded in the needs of individual patients and society. There is much evidence that this approach benefits medical schools, medical students, and patients alike.
The major driver of the paradigm shift in medical education over the past two decades has been the increasing public demand for improved safety and quality.We now have a national mandate for competency-based education from the Accreditation Council of Graduate Medical Education (ACGME) Outcome Project and the American Board of Medical Specialties (ABMS) Maintenance of Certification Program, as well as similar international efforts in Canada, the United Kingdom, and elsewhere. The public expects physicians to be caring, compassionate, ethical, and patient-centered, as well as competent in clinical care.
We have the necessary technology to guide learning in this new way and promising new approaches to assessment. Our “digital native” students expect to rapidly search for information rather than commit reams of facts to memory. Emerging evidence from K-12 education suggests that transitioning to a competency-based framework can transform the classroom and dramatically speed progression of students through the curriculum. We are on the cusp of exciting changes in the formation of a physician across the continuum, from pre-med to mature practice.
Under a competency-based system, all physicians are required to demonstrate core competencies for their medical specialty. This means acquiring skills beyond the traditional areas of medical knowledge and diagnostic acumen, to include skills that will enhance quality and patient-centered care as well as a commitment to improving systems of care. Moving physician formation beyond these traditional domains has been increasingly emphasized since the release of six core domains of competence by ACGME/ABMS in 1999:
- Patient care
- Health science knowledge
- Practice-based learning and improvement
- Interpersonal and communication skills
- Systems-based practice.
After a decade of work with these domains, many recognize the critical importance of adding two other essential domains: interprofessional collaborative practice (IPC), and personal and professional development (PPD).
Some may argue that competency in the domain of IPC is contained within the ACGME/ABMS competency domains of Systems-based Practice, Professionalism, and Interpersonal and Communication Skills. However, IPC is so fundamental to care in the 21st century that six health professions’ organizations, comprising the Interprofessional Education Collaborative (IPEC), agree it deserves recognition as a distinct domain of competence.
A second additional domain of competence proposed is Personal and Professional Development (PPD). This domain was the outcome of the Pediatrics Milestones Working Group. They surveyed educators who had been using the ACGME/ABMS framework for nearly a decade, to identify their perceptions of what was missing from the competencies. The educators’ overwhelming response was that the ACGME/ABMS framework provided an outstanding foundation, but did not include critical competencies in such areas as trustworthiness, the ability to manage stress, flexibility, understanding one’s limits, confidence, the ability to manage ambiguity, and the capacity for leadership. These competencies have been bundled under the new domain labeled PPD.
Where are we in 2012? With the specialty-specific competencies defined, the graduate medical community is now engaged in the next phase of the paradigm shift, developing milestones of achievement for the residency years. Milestones are defined as “achievement of a higher level of performance for a specific competency,” and place those competencies in a developmental framework to help us understand where a resident should be during the course of a one- to seven-year training program. Three specialties (Internal Medicine, Pediatrics, and Surgery) have already completed the initial draft and the remaining 20+ specialties accredited by the ACGME will complete their milestones within the next two years. The next step requires “in vivo” testing of the milestones as prelude to developing new learner assessment tools.
Here at the AAMC, we are working with constituents on innovations to extend the competency-based framework to the medical school admissions process. Henry Sondheimer and Steve Fitzpatrick, using two recent landmark AAMC publications, are leading conversations to define the competencies that are optimal for entry to medical school.
Exciting pilot projects such as TIME and EPAC are exploring how to “individualize” learning for medical students and residents at key transition points in their education. Both programs aim at giving learners a “roadmap” to competency, providing the appropriate learning opportunities to achieve those competencies, and then allowing them to advance based on competence rather than time.
We are at a turning point in educational innovation in this country, and medical education is no exception. Ten years after the launch of the ACGME Outcome project, the paradigm shift to CBME is taking shape; there is no turning back. We look forward to creating the future with all of you, as we seek to continually improve physician formation across the continuum to meet the demands of the 21st century health care system.
—Carol Aschenbrener, MD, is the Chief Medical Officer at the AAMC. Prior to her work at the AAMC, she spent nine years in various dean’s office positions at the University of Iowa College of Medicine and four years as chancellor of the University of Nebraska Medical Center. She can be reached at email@example.com.
—Robert Englander, MD, MPH, is the Senior Director of Competency-based Learning and Assessment at the AAMC. He formerly served as the Senior Vice President for Quality and Patient Safety at the Connecticut Children’s Medical Center and Professor of Pediatrics at the University of Connecticut School of Medicine. He can be reached at firstname.lastname@example.org.
—Jan Bull, MPA, is the Lead Specialist in Competency-based Learning and Assessment at the AAMC. Jan has over 30 years of experience in the field of health care policy and research. She can be reached at email@example.com.