When competency comes first: 10 years of training family physicians with CBME
For over 100 years, medical education – medical school and residency – have looked largely the same. Students moved through a series of curricular units: in the classroom, lab and in clinical settings, and their evaluation was largely time-based. A completed rotation, and on to the next. Just over 10 years ago, there was a push in North America to start looking at medical education in a new way. Instead of completed units of time, future doctors would be evaluated on their competencies. And this type of evaluation could dramatically improve patient safety outcomes. At the forefront of this movement, was Queen’s University. The Department of Family Medicine was one of the first programs in the country to implement Competency Based Medical Education (CBME). In the 10 years since its implementation, CBME has been integrated across every postgraduate training program in the School of Medicine, making it the first school in Canada to make this shift across all programs. With a greater emphasis on individualized learning, preparedness for practice and frequent and meaningful feedback, CBME has improved the quality of medical education at Queen’s and across the world.
Drs. Jane Griffiths and Karen Schultz played a major role in implementing and expanding the CBME program at Queen’s. Drs. Griffiths and Schultz were the Assessment and Curriculum Directors in the Department of Family Medicine during a time when the program was expanding to include three new locations in Belleville, Peterborough and Oshawa. They took this as an opportunity to build CBME into these new sites from the ground up, while implementing it simultaneously in Kingston.
“There was a concern that perhaps we weren't training people to be as competent as they could be by the time that they went out into practice. CBME forces us to look at how we're educating people and see if we can be doing it better,” says Dr. Schultz. “We became one of the few programs in the world that was CBME-based and it was a really wonderful opportunity to take these new concepts and use them to build brand new sites and to also look at our existing site and make sure that the concepts within CBME are being reflected.”
Since its implementation, CBME has been shown to have a positive impact on students and educators. Where previously there had been end of rotation assessments, CBME recognizes the flaws in resting on one kind of assessment and incorporates a multi-pronged approach. Preceptors take day-to-day assessments and provide residents with regular feedback. This has allowed preceptors to optimize training for all residents--to identify students who are struggling and provide personalized support earlier in their residency and to provide more challenging learning opportunities for residents who are doing well.
“One other big thing that started to become apparent was that residents who were in difficulty were identified earlier. That allowed us to put more energy into supporting them to do better, rather than just wondering if they're going to make the mark and whether our assessment system was going to identify them,” says Dr. Griffiths. “We have a very short program; it's only two years. So, someone not meeting the mark and taking six months to identify that and to pull in supports, that’s a quarter of their program. It’s too long to wait.”
CBME also improves students’ self-assessment skills. “We will often have a resident self-assess and then compare that with an external assessor,” says Dr. Schultz. “Most of the residents are pretty good at this but some are overconfident, and some are underconfident. Now we can see where there are differences, and we can start to have the conversations about how to calibrate their sense of their skills to be more accurate.”
As one of the first schools to implement the curriculum, Queen’s has seen an increase in research and publications related to educational work. “CBME has allowed our faculty members to take part in educational scholarship and give presentations at national and international conferences and that has been very gratifying as well,” says Dr. Schultz. Educators at Queen’s have benefitted from a platform designed by Dr. Griffiths, in which students can rate their feedback and explain if and why they found it to be beneficial to their learning. This instant feedback helps educators to further improve the way that they train learners.
“After a few years of using the portfolio, Dr. Schultz and I and a few others did a research project where we interviewed the preceptors,” says Dr. Griffiths. “It showed that the heightened attention to assessment and feedback made our educators feel like better teachers and better preceptors. That was one of the first times I felt that this change we created really was working and that the culture of assessment in our department really was changing for the better.”
Both Drs. Schultz and Griffiths believe that moving forward the CBME program at Queen’s will continue to grow. “Every year I would sit down with every single preceptor in the whole family medicine department and talk to them about the portfolio, new ideas about field notes or assessment, and I would ask them if they had any ideas about how to make the system easier to use,” says Dr. Griffiths. “This iterative work and listening to all of the people who are involved with CBME has gradually improved the whole system year by year.”
As the newly appointed Associate Dean for Postgraduate Medical Education, Dr. Schultz is particularly interested in how collaboration between the Family Medicine program and the Royal College programs can improve CBME moving forward. While they use the same principles, The Royal College of Physicians and Surgeons of Canada goes about CBME, which they call Competency by Design, in a different way than the College of Family Physicians of Canada’s Competency-based Triple C Curriculum. Dr. Schultz is hopeful that increased communication can help explore these differences and improve all the programs by gathering the best ideas. “One of the challenges at the beginning was being pretty isolated in what we were doing with our work,” says Dr. Schultz. “Now I think we're at the stage where we can start those talks with other programs and organizations and together strengthen our approaches by learning from each other.”