Residents prepare for switch to competency-based medical education

[Leon]

Residents prepare for switch to competency-based medical education

 

Beginning in 2017, medical residents training in Canadian teaching hospitals will be part of the biggest transformational change in medical education since 1910, when Sir William Osler introduced the residency training model still in use today.

 

Under the Royal College’s new Competency-Based Medical Education (CBME) model, residents will be required to demonstrate competencies that will be spelled out according to their stage of development as a physician, not simply by the number of years in a residency program.

 

The Canadian Association of Internes and Residents sees the change as necessary. Vice President Dr. Mathieu Dufour, a resident in forensic psychiatry, says more work for the preceptors and residents is to be expected during the transition years when the new model is being introduced.

 

Is it just me or does this seem to suggest you could technically be in residency forever? An easy source of cheap labour for hospitals strapped for $$$.....

[tberry3]

Is it just me or does this seem to suggest you could technically be in residency forever? An easy source of cheap labour for hospitals strapped for $$$.....

 

I didn't read it that way, although the article was a bit vague so it's hard to say exactly what these changes will look like in real life. My interpretation is just that they'll be evaluating residents differently than they currently do, not necessarily that the basic framework of how residency works will be fundamentally changed.

[dazzle]

Is it just me or does this seem to suggest you could technically be in residency forever? An easy source of cheap labour for hospitals strapped for $$$.....

 

Or finished quicker?

[Leon]

Or finished quicker?

 

I think that's unlikely....the residents are at the mercy of the administration here and while in theory this sounds like an awesome plan to ensure higher quality physician training, there is so much abuse in the system that I can't help but wonder how internal politics are going to affect the duration of residencies....

 

You cross your attending and he/she could hold you back from finishing, lol. I'm guessing some kind of cap will be implemented to ensure that this type of thing doesn't happen but then a cap would technically void the policy itself- the policy requires you to spend extra time if necessary to learn critical skills and imposing a cap would kind of negate that. They have another 4 years to hash out the details so I'm interested in seeing how they are going to structure this. Very interested indeed.

[ChemPetE]

Well that's what U of T's ortho program is up to. They're trialling a competency based model instead of a timed based model. This year was the first year their cohort sat the Royal College exam, although I have been out of the loop these past few months so I'm not sure how that went for all of them (though my guess is that they all passed).

[NLengr]

We have been told that surgical royal college exams will likely integrate simulation stations into the Osce portion as part of these changes. So surgical skill will be evaluated.

 

Luckily I'm done before 2017. I imagine the transition will be a bit of a mess while wrinkles are ironed out.

 

This might be a good thing overall depending how aggressive work hour restrictions are (if they are widely implemented). If we are limited to 50 hrs like the EU, then this would be a better way to eval. It just needs to be monitored for abuse (I.e. perpetual cheap labour).

[ellorie]

I wonder what will happen to those of us caught in the middle. I'll be starting R3 that year.

[penguin92]

I wonder what will happen to those of us caught in the middle. I'll be starting R3 that year.

 

I'm also wondering about this. I'd be in PGY-1

[jock2doc]

What was the process the Royal College went through when deciding to switch to this model? Also, depending on how strict their competency requirements are, do you think this will have any affect on the trend of multiple fellowships after residency? (Thinking of surgical residencies in particular)

[NLengr]

I wonder what will happen to those of us caught in the middle. I'll be starting R3 that year.

 

I would expect that if you are already started residency at that point you'd keep going under the old system. 2017 PGY-1's would probably be the first cohort.

[thebouque]

It's canmeds version 2.0. The length of residency programs will probably not be affected by the competency based approach. You'll mostly see the change in your program description and your ITERs. Other than that, I'm sure it'll be pretty similar to our current system.

[ralk]

A lot of interesting statements there that could go any number of ways... I hope they release details on their plans soon (or include us test-rats in the process as well!)

 

My initial thought is that they're simply going the route a lot of other health care professions have gone. I imagine there'll still be a set training time, but it can be extended if a certain number of competencies aren't achieved.

 

I like the focus on competence rather than knowledge, but a lot of competency-based evaluation structures can be counterproductive. Constantly testing competence means students (or in this case residents) spend a lot of their time trying to figure out how to pass the test rather than actually gaining competency. This is especially true in medicine, where each practitioner has their own way of doing things and are often critical of other methods - meaning the test is often more about whether you can match your evaluator's preferences than anything else!

[BoyInTheBubble]

Or finished quicker?

 

The idea is that you're done when you are good enough.

 

So yes, good residents can (and should) finish earlier. If you think about it, why would so many residents learn at a 5 year pace?? There are clearly some who learn faster, some who learn slower, and yet most people will likely still finish around the 5 year mark. The system doesn't allow for delays. If you need 4 extra blocks of something before you begin independent practice, you shouldn't be limited because your 5 year program is up.

 

The real challenge is how to define competencies, and how to measure a resident's competence. Currently, the system relies heavily on the final college exams, but this change is supposed to improve the evaluation of residents. It will be challenging to remove the ambiguity. The process will take years to work out the kinks.

 

Does (doing a poor job at) 100 appy's mean you can do them on your own? What about the superstar who has the technique down after 12? You don't really need to see the next 88.

[Laika]

Residencies are going to be longer. Full stop.

 

Any evidence, or just a prediction? The only resident I know in a competency based residency program wrote the royal college a year early, and passed...

[NutritionRunner]

A lot of interesting statements there that could go any number of ways... I hope they release details on their plans soon (or include us test-rats in the process as well!)

 

My initial thought is that they're simply going the route a lot of other health care professions have gone. I imagine there'll still be a set training time, but it can be extended if a certain number of competencies aren't achieved.

 

This. There are several health professions that already base their evaluation of interns/trainees on competencies. If an individual doesn't demonstrate the required competencies, then their training can be extended. In dietetics at least, where trainees have to do a year long unpaid internship in order to qualify to write the dietetic practice exam, training can be extended if the basic competencies of an entry-level dietitian are not met (although from what I'm told, it's a fairly rare occurrence, but does occasionally happen).

[ellorie]

If people were finishing early, wouldn't that mess things up though? Programs seem to be based around the idea that they will have a certain number of residents in each year to do what needs to be done.

[rmorelan]

If people were finishing early, wouldn't that mess things up though? Programs seem to be based around the idea that they will have a certain number of residents in each year to do what needs to be done.

 

Only if one average people didn't collectively end at the same time - it is the entire service vs education aspect to residency. We already have to handle maternity/paternity leave, and education leave so the system has to have some slack in any case.

[rmorelan]

I can see under this system residents even more fighting for the procedures/cool cases etc to expand their understanding and end early or at least one time. No one wants to be left at the end

[ralk]

This. There are several health professions that already base their evaluation of interns/trainees on competencies. If an individual doesn't demonstrate the required competencies, then their training can be extended. In dietetics at least, where trainees have to do a year long unpaid internship in order to qualify to write the dietetic practice exam, training can be extended if the basic competencies of an entry-level dietitian are not met (although from what I'm told, it's a fairly rare occurrence, but does occasionally happen).

 

I just finished up a program with a similar structure Same situation, failures were rare and generally only occurred in the case of extreme incompetence or apathy on the part of the student. Some students definitely struggled, but their supervisors just put in a bit of extra effort to ensure they hit the minimum competencies in time.

 

It's tough because the standard is "entry-level", which is easy to understand, but fairly vague. Having had the chance to actually work at the job now, I find I'm still learning a ton. It's not like people come out of health care practitioner programs, or residency, knowing everything or being able to do everything perfectly.

[A-Stark]

I can see under this system residents even more fighting for the procedures/cool cases etc to expand their understanding and end early or at least one time. No one wants to be left at the end

 

This. I think this can be something of an issue now, if mainly in surgery.

[lalab]

This. I think this can be something of an issue now, if mainly in surgery.

 

Aren't interesting cases discussed in rounds? I'm sure it's not the same as operating the case first hand, but wouldn't you learn anyways?

[A-Stark]

You'll definitely learn about surgical decision-making, but as with any procedure, reading/hearing about it is not the same as doing it. Someone can explain how to do an LP for hours and it still won't help you become comfortable with doing one.

 

In other specialties this isn't necessarily an issue. In medicine, there are certainly many residents who crave and seek out procedures wherever possible, but there's an equal or greater number who don't really care or even actively avoid them.

[ralk]

You'll definitely learn about surgical decision-making, but as with any procedure, reading/hearing about it is not the same as doing it. Someone can explain how to do an LP for hours and it still won't help you become comfortable with doing one.

 

In other specialties this isn't necessarily an issue. In medicine, there are certainly many residents who crave and seek out procedures wherever possible, but there's an equal or greater number who don't really care or even actively avoid them.

 

I suppose it'll depend on what they insist upon for competency and how it becomes evaluated. If they now insist that medical specialists have some level of competence in procedures, there'll definitely be more competition to participate in those.

 

Obviously it'll be different for residents than other health care programs, but in my training, for the rarer procedures, you didn't actually have to do the procedure yourself to be considered competent. Heck, some procedures came up once or twice a year. Since there were more trainees than that at a typical site, there's no way actually doing the procedure could be necessary for competence to be achieved - there weren't enough of them to go around!

 

But problems definitely arose in the uncommon procedures. These happened often enough that trainees had to demonstrate competence by doing the procedure, but not often enough that they could become truly comfortable with the procedure. Those caused fights...

[NLengr]

Aren't interesting cases discussed in rounds? I'm sure it's not the same as operating the case first hand, but wouldn't you learn anyways?

 

How good of a baseball player do you think you would be if you discussed batting all day, but never swung a bat.

 

Surgical expertise is all about repetition. You need to physically do the operations many times before you are any good. There is good literature to show that in order to remain at peak ability to perform an operation, you should be doing the surgical procedure about 20-25 times per year or more.

[rmorelan]

How good of a baseball player do you think you would be if you discussed batting all day, but never swung a bat.

 

Surgical expertise is all about repetition. You need to physically do the operations many times before you are any good. There is good literature to show that in order to remain at peak ability to perform an operation, you should be doing the surgical procedure about 20-25 times per year or more.

 

Not as extreme but similar to other things as well. Knowledge and skills are two different things - you need both but if all you do is classroom instruction you would be basically useless in almost any medicine field.

 

I cannot really learn how to interpret images even - arguably a purely intellectual exercise even - by reading about it or powerpoint presentations. I have to actually do it, and do it over and over again.