A qualitative study of Canadian resident experiences with Competency-Based Medical Education
DOI:
https://doi.org/10.36834/cmej.72765Abstract
Background: Competency-based medical education (CBME) is an outcomes-based curricular paradigm focused on ensuring that graduates are competent to meet the needs of patients. Although resident engagement is key to CBME’s success, few studies have explored how trainees have experienced CBME implementation. We explored the experiences of residents in Canadian training programs that had implemented CBME.
Methods: We conducted semi-structured interviews with 16 residents in seven Canadian postgraduate training programs, exploring their experiences with CBME. Participants were equally divided between family medicine and specialty programs. Themes were identified using principles of constructivist grounded theory.
Results: Residents were receptive to the goals of CBME, but in practice, described several drawbacks primarily related to assessment and feedback. For many residents, the significant administrative burden and focus on assessment led to performance anxiety. At times, residents felt that assessments lacked meaning as supervisors focused on “checking-boxes” or provided overly broad, non-specific comments. Furthermore, they commonly expressed frustration with the perceived subjectivity and inconsistency of judgments on assessments, especially if assessments were used to delay progression to greater independence, contributing to attempts to "game the system". Faculty engagement and support improved resident experiences with CBME.
Conclusion: Although residents value the potential for CBME to improve the quality of education, assessment and feedback, the current operationalization of CBME may not be consistently achieving these objectives. The authors suggest several initiatives to improve how residents experience assessment and feedback processes in CBME.
References
Frank JR, Snell LS, Cate O Ten, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32:638–45. https://doi.org/10.3109/0142159X.2010.501190
ten Cate O. Competency-based postgraduate medical education: past, present and future. GMS J Med Educ. 2017;17;34. https://doi.org/10.3205/zma001146
Tannenbaum D, Kerr J, Konkin J, et al. Triple C competency-based curriculum. report of the working group on postgraduate curriculum review – part 1. Coll Fam Physicians Canada. 2011;1:101.
Oandasan I, Wong E, Saucier D, Donoff M, Iglar K, Schipper S. Triple C: linking curriculum and assessment. Can Fam Physician. 2012;58:1165.
The Royal College of Physicians and Surgeons of Canada. What is CBD? Available from: https://www.royalcollege.ca/rcsite/cbd/what-is-cbd-e [Accessed Jun 30, 2020].
Ten Cate O, Scheele F, Ten Cate TJ. Viewpoint: competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542–7. https://doi.org/10.1097/ACM.0b013e31805559c7
Lockyer J, Carraccio C, Chan MK, et al. Core principles of assessment in competency-based medical education. Med Teach. 2017;39:609–16. https://doi.org/10.1080/0142159X.2017.1315082
Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: from flexner to competencies. Acad Med. 2002;77:361–7. https://doi.org/10.1097/00001888-200205000-00003
Van Melle E, Frank JR, Holmboe ES, Dagnone D, Stockley D, Sherbino J. A Core components framework for evaluating implementation of competency-based medical education programs. Acad Med. 2019;94:1002–9. https://doi.org/10.1097/ACM.0000000000002743
Oandasan IF, Saucier D, (eds). Triple C Competency-based Curriculum Report – Part 2 Advancing Implementation Mississauga, ON: College of Family Physicians of Canada; 2013. https://portal.cfpc.ca/resourcesdocs/uploadedFiles/Education/_PDFs/TripleC_Report_pt2.pdf. [Accessed Sept 20, 2020].
Cate O Ten, Carraccio C. Envisioning a true continuum of competency-based medical education, training, and practice. Acad Med. 2019;94:1283–8. https://doi.org/10.1097/ACM.0000000000002687
Gofton W, Dudek N, Barton G, Bhanji F. Workplace-based assessment implementation guide: Formative tips for medical teaching practice. The Royal College of Physicians and Surgeons of Canada. 2017;1st ed.:1–12. Available at: 12. http://www.royalcollege.ca/rcsite/documents/cbd/wba-implementation-guide-tips-medical-teaching-practice-e.pdf
Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32:676–82. https://doi.org/10.3109/0142159X.2010.500704
Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach. 2010;32:631–7. https://doi.org/10.3109/0142159X.2010.500898
Gruppen LD, ten Cate O, Lingard LA, Teunissen PW, Kogan JR. Enhanced requirements for assessment in a competency-based, time-variable medical education system. Acad Med. 2018;93:S17–21. https://doi.org/10.1097/ACM.0000000000002066
ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39:1176–7. https://doi.org/10.1111/j.1365-2929.2005.02341.x
Ellaway RH, Mackay MP, Lee S, et al. The impact of a national competency-based medical education initiative in family medicine. Acad Med. 2018;93:1850–7. https://doi.org/10.1097/acm.0000000000002387
Hsu T, De Angelis F, Al-asaaed S, Basi SK, Tomiak A, Grenier D, et al. Ten ways to get a grip on designing and implementing a competency-based medical education training program. Can Med Educ J. 2021;12. https://doi.org/10.36834/cmej.70723
ICE Blog. Introducing a core components framework for competency-based medical education. Available from: https://icenetblog.royalcollege.ca/2021/11/18/introducing-a-core-components-framework-for-cbme/ [Accessed on Dec 30, 2021].
Lim J, Westerman ME, Stewart NH, Correa R, Eno C. Trainee Perspectives on the writing and implementation of milestones 2.0. J Grad Med Educ. 2021;13:8–10. https://doi.org/10.4300/JGME-D-20-00859.1
Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: A charter for clinician-educators. Acad Med. 2016;91(5):645-9. https://doi.org/10.1097/ACM.0000000000001048
Harrison CJ, Könings KD, Schuwirth L, Wass V, van der Vleuten C. Barriers to the uptake and use of feedback in the context of summative assessment. Adv Heal Sci Educ. 2015;20:229–45. https://doi.org/10.1007/s10459-014-9524-6
Iobst WF, Sherbino J, Cate O Ten, et al. Competency-based medical education in postgraduate medical education. Med Teach. 2010;32:651–6. https://doi.org/10.3109/0142159X.2010.500709
Mann S, Hastings Truelove A, Beesley T, Howden S, Egan R. Resident perceptions of Competency-Based Medical Education. Can Med Educ J. 2020;11:e31. https://doi.org/10.36834/cmej.67958
Upadhyaya S, Rashid M, Davila Cervantes A, Oswald A. Exploring resident perceptions of initial competency based medical education implementation. Can Med Educ J. 2021:e42–56. https://doi.org/10.36834/cmej.70943
Branfield Day L, Miles A, Ginsburg S, Melvin L. Resident perceptions of assessment and feedback in competency-based medical education: a focus group study of one internal medicine residency program. Acad Med. 2020;95:1712–7. https://doi.org/10.1097/ACM.0000000000003315
Marcotte L, Egan R, Soleas E, Dalgarno NJ, Norris M, Smith CA. Assessing the quality of feedback to general internal medicine residents in a competency-based environment. Can Med Educ J. 2019;10:e32–47. https://doi.org/10.36834/cmej.57323
David V, Walsh M, Lockyer J, Mintz M. Entrustable professional activities: an analysis of faculty time, trainee perspectives and actionability. Can J Gen Intern Med. 2021;16:8–13. https://doi.org/10.22374/cjgim.v16i1.415
Hall AK, Rich J, Dagnone JD, et al. It’s a marathon, not a sprint: rapid evaluation of competency-based medical education program implementation. Acad Med. 2020;95:786–93. https://doi.org/10.1097/ACM.0000000000003040
Federation des medecins residents du Quebec. Year 3 of implementation of competence by design: negative impact still outweighs theoretical benefits observations on the day-to-day reality of CBD. 2020.
Schultz K, Griffiths J. Implementing competency-based medical education in a postgraduate family medicine residency training program: a stepwise approach, facilitating factors, and processes or steps that would have been helpful. Acad Med. 2016;91:685–9. https://doi.org/10.1097/ACM.0000000000001066
Hamza DM, Ross S, Oandasan I. Process and outcome evaluation of a CBME intervention guided by program theory. J Eval Clin Pract. 2020;26:1096–104. https://doi.org/10.1111/jep.13344
Ross S, Poth CA, Donoff MG, et al. Involving users in the refinement of the competency-based achievement system: An innovative approach to competency-based assessment. Med Teach. 2012;34. https://doi.org/10.3109/0142159X.2012.644828
Charmaz K, Belgrave LL. The SAGE handbook of interview research: the complexity of the craft. SAGE Handb Interview Res Complex Cr. 2nd ed. 2012;347–66. https://doi.org/10.4135/9781452218403.n25
Watling C, Lingard L. Grounded theory in medical education research: AMEE Guide No. 70. Med Teach. 2012;34:850–61. https://doi.org/10.3109/0142159x.2012.704439
Charmaz K. Constructing grounded theory: a practical guide through qualitative research. Sage Publications Ltd. London: SAGE Publications Ltd; 2006.
Apramian T, Cristancho S, Watling C, Lingard L. (Re)Grounding grounded theory: a close reading of theory in four schools. Qual Res. 2017;17:359–76. https://doi.org/10.1177/1468794116672914
Morse JM. The significance of saturation. Qual Health Res. 1995;5:147–9. https://doi.org/10.1177/104973239500500201
Hennink MM, Kaiser BN, Marconi VC. Code saturation versus meaning saturation: how many interviews are enough? Qual Health Res. 2017;27:591–608. https://doi.org/10.1177/1049732316665344
Martin L, Sibbald M, Brandt Vegas D, Russell D, Govaerts M. The impact of entrustment assessments on feedback and learning: trainee perspectives. Med Educ. 2020;54:328–36. http://dx.doi.org/10.1111/medu.14047
Schut S, Driessen E, van Tartwijk J, van der Vleuten C, Heeneman S. Stakes in the eye of the beholder: an international study of learners’ perceptions within programmatic assessment. Med Educ. 2018;52:654–63. https://doi.org/10.1111/medu.13532
Atkinson A, Watling CJ, Brand PLP. Feedback and coaching. Eur J Pediatr. 2021;1–6. https://doi.org/10.1007/s00431-021-04118-8
Watling C, Ginsburg S. Assessment, feedback and the alchemy of learning. Med Educ. 2019;53:76–85. https://doi.org/10.1111/medu.13645
MacNeil K, Cuncic C, Voyer S, Butler D, Hatala R. Necessary but not sufficient: identifying conditions for effective feedback during internal medicine residents’ clinical education. Adv Heal Sci Educ. 2020;25(3):641-654. https://doi.org/10.1111/medu.14154
Harrison C, Wass V. The challenge of changing to an assessment for learning culture. Med Educ. 2016;50:704–6. https://doi.org/10.1111/medu.13058
Ginsburg S, Watling CJ, Schumacher DJ, Gingerich A, Hatala R. Numbers encapsulate, words elaborate: toward the best use of comments for assessment and feedback on entrustment ratings. Acad Med. 2021;96:S81–6. https://doi.org/10.1097/ACM.0000000000004089
Malone K, Supri S. A critical time for medical education: The perils of competence-based reform of the curriculum. Adv Heal Sci Educ. 2012;17:241–6. https://doi.org/10.1007/s10459-010-9247-2
Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34:787–91. https://doi.org/10.3109/0142159x.2012.684916
Boet S, Pigford AAE, Naik VN. Program director and resident perspectives of a competency-based medical education anesthesia residency program in Canada: a needs assessment. Korean J Med Educ. 2016;28:157–68. https://doi.org/10.1111/medu.12637
Upadhyaya S, Rashid M, Davila Cervantes A, Oswald A. Exploring resident perceptions of initial competency based medical education implementation. Can Med Educ J. 2021;12(2):e42-e56. https://doi.org/10.36834/cmej.70943
Acai A, Li SA, Sherbino J, Chan TM. Attending emergency physicians’ perceptions of a programmatic workplace-based assessment system: the McMaster Modular Assessment Program (McMAP). Teach Learn Med. 2019;31:434–44. https://doi.org/10.1080/10401334.2019.1574581
Gaunt A, Patel A, Rusius V, Royle TJ, Markham DH, Pawlikowska T. ‘Playing the game’: How do surgical trainees seek feedback using workplace-based assessment? Med Educ. 2017;51:953–62. https://doi.org/10.1097/acm.0000000000001523
Leung WC. Competency based medical training: review. BMJ. 2002;325 (7366):693–6. https://doi.org/10.1136/bmj.325.7366.693
Pinsk M, Karpinski J, Carlisle E. Introduction of competence by design to Canadian nephrology postgraduate training. Can J Kidney Heal Dis. 2018;5. https://doi.org/10.1177/2054358118786972
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2022 Leora Branfield Day, Terry Colbourne, Alex Ng, Franco Rizzuti, Linda Zhou, Rani Mungroo, Allan McDougall
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Submission of an original manuscript to the Canadian Medical Education Journal will be taken to mean that it represents original work not previously published, that it is not being considered elsewhere for publication. If accepted for publication, it will be published online and it will not be published elsewhere in the same form, for commercial purposes, in any language, without the consent of the publisher.
Authors who publish in the Canadian Medical Education Journal agree to release their articles under the Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 Canada Licence. This licence allows anyone to copy and distribute the article for non-commercial purposes provided that appropriate attribution is given. For details of the rights an author grants users of their work, please see the licence summary and the full licence.
