Part 6 – Competence By Design

Today, Dr. Jolanta Karpinski from the Royal College of Examiners presented on the topic of Competency Based Medical Education during a special CEEP rounds. Essentially, the entire Canadian medical and surgical residency program is undergoing a massive overhaul with a singular mandate to update the current way we train residents into competent physicians.  She argued that though the current system trains excellent doctors, the reality is that it is outdated and the evidence suggests that our methods could be much improved upon. The current model assumes that the more time a learner spends on an activity; the more the learner absorbs and excels. This method, however, has had difficulty keeping up with the increasing scope, demands, and complexities of medical care. As such, more and more newly graduated specialists have identified increasing knowledge gaps and a feeling of unpreparedness for independent practice. The system has also identified that educators are struggling to define clear learning objectives and adequate assessment tools; and as such is finding it difficult to determine when a learner is falling behind. In other words, how does one define the quality of their assessment program?

The solution, one hopes, comes with Competency By Design, which is not CBME in its purest form as it is unlikely to change the length of training program, but instead, it re-conceptualizes time as a resource for acquiring competencies. It is outcome based and is designed around the question: “What abilities do physicians need at each stage of their career?” It organizes physician training around desired hard outcomes that must be accomplished - known as EPA’s – entrustable professional activities.  EPA’s are tasks that integrate a number of milestones and abilities that are given by supervisors in a clinical setting to determine competence. EPA’s are designed around the CanMED roles. And ultimately, the Royal College will grant board certification via the successful completion of the licensing examination AND required EPA’s.

I think overall, this is the right move towards modernizing our medical education and in producing higher quality physicians. My dispute though, is that if that we’re trying to move towards competency based education, then why shouldn’t there be an option for a shorter training program if the resident is indeed competent for independent practice. For example, in this year’s entering ophthalmology residency class, there is a foreign trained ophthalmologist who also completed an additional 2-year vitreoretinal fellowship at the University of Toronto – however in order to remain and practice in Canada, the system mandates he retrain in a Canadian ophthalmology residency program. Is he competent as a PGY 1,2,3,4? I would think so, and it would be very easy to assess whether he can perform all the EPA’s capably. Should he not be allowed to fast track a true Competency By Design residency-training program? I would hope so…

 My realistic/pessimistic thoughts are that for every residency program, there is still very much a “service component” that needs to be fulfilled, and having “independent practice ready” residents graduate sooner will leave a huge void in this service. Residents who are ‘left behind’ will have an unrealistic demand in work in addition to the logistical nightmare this will create. However, my hope is as implement CBD in our residency training, we will eventually evolve to true CBME. 

I look forward to seeing the manifestations of the incoming CBD model of training, especially as I, myself, transition from medical student to resident. – AC