After a discussion about competency-based
programs, I took the opportunity to read “A tea-steeping or i-Doc model for
medical education” by Dr. Brian Hodges (http://www.ncbi.nlm.nih.gov/pubmed/20736582).
The article explores two different paradigms in medical education, and how they
could be reconciled and applied to current needs to medical education.
The
first example that Dr. Hodges discusses is the traditional “tea steeping” model
that is fairly familiar to those of us currently in medical school. The “tea
steeping” model is the predominant one currently, and refers to the fixed
duration of medical training (three or four years), after which it is assumed
that a learner will become a competent practitioner. In other words the tea is the student, and
the hot water is the school. This model is firmly entrenched, and a complete
departure from it would be quite difficult. Changes have been made to it over
time, such as modifying the curriculum, admissions requirements, or lengthening
the time of training.
Issues with the “tea steeping” model
include issues with evaluation of trainee performance (often at the end of
rotations or courses rather than continuous assessments) and a disconnect
between the basic sciences and clinical training. However, at the same time Dr.
Hodges states that model may be better for developing habits of mind such as
cognitive flexibility and tolerance of ambiguity.
The second model of competence development
that Dr. Hodges describes is an outcomes-based one. He describes it as the
“iDoc” model, drawing parallels between manufacturing iPods and manufacturing
trainees that have a certain set of competencies (in fact he describes how some
of the language surrounding outcomes based training reflects that used in
manufacturing). In this model, students
progress when they demonstrate competency in certain areas. For example, the
orthopedic surgery residency program at the University of Toronto ensures that
residents gain mastery of skills in modules such as basic fractures, complex
trauma, and pediatric orthopedics. While this model could make training programs
more efficient, the logistical issues (organizing rotations, preceptors, and
dealing with variable length of training) would likely preclude full
implementation.
As a medical student (for a few more
months) I generally agree with the benefits and drawbacks of each model. There
are times when I reflect on how much time is left until July 1st and
begin to feel somewhat worried about skills I have not mastered or
presentations I have not yet seen. As a future resident, I would feel reassured
to be in a program where I have to demonstrate clear competency in certain
important domains before being considered “fully trained”. However at the same
time, I wonder if my mastery of skills would suffer with time after completing
the “module” in which it was taught. I can appreciate that the logistics would
be difficult to manage, and the variable length of training would make it
difficult to plan my career around. In
terms of the “tea-steeping” model, I have appreciated the fact that I was
immersed in a four-year journey of learning. I was able to take this time to
develop new ways of thinking and approaching problems, and didn’t feel
pressured to take on the next module so I could move forward.
Like Dr. Hodges, I feel that integrating
outcome-based training into the four-year curriculum would be a good approach.
In some ways I can see this happening already, with our observed histories and
physicals in our family medicine rotation (FM-CEX) and the mandatory patient encounters
that we have to log for each rotation (though these are not evaluated). I believe
that a formalized system for continuous evaluation and feedback during clinical
work for each rotation (not just halfway through and at the end) would be a
possible next step that I would like to see done.
-SR
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