Competency-based education has been a concept in medical education since the 1970s, though has only gained traction and application in programs in the last 15-20 years. Multiple competency models exist (e.g. CANMeds, ACGME), though ACGME is prevalent in the US and is the focus of this presentation. The most common tensions in the competency-based education movement exist around: the deconstruction of clinical practice over respect for the complexity of the tasks; the challenge of appropriate assessments; and when to know to trust a resident with increasing responsibilities. The benefits and challenges are discussed; the session closes with an exploration of three case studies, drawing from different geographical regions (US, Canada, Australia), as a way to help participants appreciate the issues in implementating competency-based education in residency programs. Prepared for and presented to Teaching Scholars Program, University of Colorado School of Medicine, Dec 18, 2012. Available under Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. References used within the presentation available upon request - email author please.

2. 'The greatest
obstacle to
discovery is not
ignorance, it is
the illusion of
knowledge’
- Daniel J.
Boorstin

3. What has been
the history of
competency-
based education
in your
department,
division or
clinical
education?

4. OVERVIEW
Definitions
Models
Benefits & Challenges
Examples in Practice
• Lessons learned

5. C O M P E T E N C Y-
PREVIOUSL
BASED
Y
E D U C AT I O N
Apprenticeship + • Competency is an
Knowledge = Training outcome
• Evaluation focused on • Standardization of
knowledge, some skills outcomes with the
• Knowledge drove the flexibility in how
curriculum design learners achieve
process these

6. HISTORY OF COMPETENCY-BASED MED ED
“…by using competencies as an organizing
framework, educators have an opportunity to
address these issues by designing learning
experiences that continuously incorporate prior
learning elements and emphasize observable
abilities.”
(McGaghie 1978; Voorhees 2001a; Carraccio et al. 2002)

7. MODEL: CANMEDS COMPETENCIES

8. ACGME

11. PATIENT CARE
Provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health.

12. MEDICAL KNOWLEDGE
Demonstrate knowledge of established and evolving
biomedical, clinical, epidemiological and social-behavioral sciences, as
well as the application of this knowledge to patient care.

13. PRACTICE-BASED LEARNING AND IMPROVEMENT
Demonstrate the ability to investigate and evaluate their care of patients, to
appraise and assimilate scientific evidence, and to continuously
improve patient care based on constant self-evaluation and life-long
learning.

14. INTERPERSONAL AND COMMUNICATION SKILLS
Demonstrate interpersonal and communication skills that result in the
effective exchange of information and collaboration with patients, their
families, and health professionals.

15. PROFESSIONALISM
Demonstrate a commitment to carrying out professional responsibilities
and an adherence to ethical principles.

16. SYSTEMS-BASED PRACTICE
Demonstrate an awareness of and responsiveness to the larger context and
system of health care, as well as the ability to call effectively on other
resources in the system to provide optimal health care.

18. PEDIATRICS

19. EMERGENCY MEDICINE

20. DEFINITIONS
Competency
What a person can do upon completion of
training
Objective
What a student should be able to do at the end
of a single learning experience

21. COMPETENCIES & OBJECTIVES
“Competency is an observable ability of a health professional, integrating
multiple components such as knowledge, skills, values and attitudes.
Since competencies are observable, they can be measured and
assessed to assure their acquisition. Competencies can be assembled
like building blocks to facilitate progressive development.”

22. ENTRUSTABLE PROFESSIONAL ACTIVITIES (EPA)
1. Identify the principal clinical responsibilities in a particular
medical specialty
2. Map these clinical responsibilities to core competencies most
important to each responsibility. These are the EPAs
ten Cate & Scheele, 2007; ten Cate, 2011

23. ENTRUSTABLE PROFESSIONAL ACTIVITIES (EPA)
3. Allow progressive independence of the resident to perform the
EPA without direct supervision
ten Cate & Scheele, 2007; ten Cate, 2011

24. EPA FOR PEDS

25. HOW DO YOU KNOW WHEN TO TRUST?
• Trustworthiness: knowledge &
skill, discernment, conscientiousness, truthfulness
(Kennedy et al, 2008)
• Self-assessment in action: slowing down, seeking help
(Eva et al, 2005)
• Global evaluations identify difficulties, not trust (Williams
et al, 2003)
• In-training exam, OSCE, mini-CEX tangential to integrated
professional functions
(Jones, Rosenberg, Gilhooly, Carraccio, 2011)
• Close resident-faculty relationship in longitudinal
settings proposed as best
(Jones, Rosenberg, Gilhooly, Carraccio, 2011)

26. MODEL: COMPETENCY DEVELOPMENT
Requires:
Time
Self-Awareness
Mentorship
Access to resources
Dr. Will Taylor, National College of Natural
Medicine, Portland, Oregon; 2007

28. BENEFITS
• Focuses on learner’s development (needs)
• Promotes continuum of expertise development and/or education
• De-emphasize time-based training
• Potentially more portable training
• Challenges community to discourse on physician competence
• Conceptualizes assessment as a formative and summative tool
• Measurable outcomes lead to fulfilling social contract

29. CHALLENGES
• Reductionism
• Lowest common denominator – bar to step over, not jump over & to
next opportunities
• Overemphasis on outcomes (what about apprenticeship?)
• Logistical/scheduling chaos
• Resources needed
• Instructional design knowledge and/or educational technologies needed

32. CASE STUDIES

33. RESIDENCY & COMPETENCIES
“PGME would benefit from a matrix educational
model that further retains the professional
maturation elements of the apprenticeship model
while integrating a competency-based model that
includes explicit expectations and assessment yet
being cautious and avoiding the risk of
deconstruction of practice into ever smaller units of
competence or of focusing on only those
competencies that are easy to describe and
assess.”
- Association of Faculties of Medicine of Canada, 2011