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Information On Competency Based Medical Education (Cbme) At Queen's


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Hello!

 

As many of you may know, Queen's is implementing Competence By Design (CBD - the Canadian CBME curriculum) on an accelerated timeline. All first year residents in July 2017, in all Queen’s programs, will be under CBD. 

 

By way of introduction, I am a member of the Resident Subcommittee on Competency Based Medical Education at Queen's. Part of our mandate is to disseminate information about the CBD program being implemented this upcoming year to final year medical students applying for residency this year. This information will also apply to those applying for Anesthesia and ENT, as Competence By Design is being introduced in those specialties across Canada. Many of you may see a similar e-mail in the next few weeks as we try to get this information out as broadly as possible.

 

This post will hopefully answer any questions you may have about CBME at Queen's. Before I start - if this e-mail and the links at the end don't answer your questions, you can e-mail cbme@queensu.ca to reach the CBME Resident subcommittee. I will monitor this post, as well, to hopefully clarify any misconceptions in the discussion. Furthermore, there will be many opportunities to ask questions on your interview day.  

 

*NOTE*: The following information is primarily for Royal College residency programs (ie. excluding Family Medicine), since Family Medicine transitioned to the triple C curriculum several years ago.  

 

1. What is CBME?

 

The bottom line: Residency will not change dramatically.

The perks: Incoming residents will have multiple tools available to them to enhance their residency education.

 

CBME shifts the focus of residency training from short-term, rotation based objectives, to long-term residency outcome objectives (ie. what does this physician need to know and be equipped with for independent practice?). The result is clearly outlined educational objectives with provision of more frequent assessment and feedback with tailored, actionable steps towards achieving your goal, or ‘competence’.

 

The Royal College has mandated that all Canadian programs are structured under the Competence by Design (CBD – the Canadian CBME curriculum) curriculum by 2022, on a rolling timeline dependent upon the specialty. This is a hybrid model of CBME within a time-based structure so RESIDENCY WILL NOT BE SHORTENED. At least not in this upcoming year – there is a potential for this in the future. Queen's is implementing CBD on an accelerated timeline. All first year residents in July 2017, in all Queen’s programs, will be under CBD.

 

Rather than the traditional PGY 1-5, residency under CBD is broken down into four stages: 

Stage 1: "Transition to Discipline" 

Stage 2: "Foundations of Discipline" 

Stage 3: "Core of Discipline" 

Stage 4: "Transition to Practice". 

 

2) What are EPAs and Milestones?

Milestones are observable markers of a learner’s ability along a developmental continuum. You can think of them like "steps across a pond".

 

Entrustable Professional Activities (EPAs) are discrete, observable, clinical tasks that a supervisor may delegate to a resident who has demonstrated sufficient competence. A specialty’s EPAs are decided upon, by consensus, at the national level. For example, all anesthesia residency programs across Canada will use the same EPAs in tailoring their training structure and assessments. EPAs not only capture clinical knowledge and procedural competence, but also the intrinsic CanMEDS roles, such as advocate, collaborator, etc. EPAs incorporate a variety of milestones in a manner that allows learners to easily track their progress through residency.

 

An example of an EPA from the Royal College in Medical Oncology:

EPA: 

- Initial Care for urgent and emergent oncologic situations

Milestones within that: 

- Recognize urgent and emergent oncologic issues, including but not limited to, pain crisis, febrile neutropenia, uncontrolled diarrhea, hypocalcemia, epidural cord compression and malignant bowel obstruction

- Select and administer appropriate interventions for urgent and emergent oncologic issues

- Identify the limits of their own expertise and appropriately seek assistance and supervision

 

3) Will Residency Be Shorter or Longer?

No - see above. Although, there is a possibility for more elective time for residents who are progress through the stages at an accelerated rate.

 

4) Will I still have 4-week rotations in residency?

Yes. The only difference is that your off-service rotation EPAs will make the experience more tailored to your specialty. 

 

5) What about current residents?

Current residents are going to benefit from the increased feedback and assessment in a similar way to the incoming residents, they just won't be officially under the CBD curriculum. 

 

6) How is this going to change my job prospects after I'm done?

It certainly won’t affect you in a negative way. If anything, the residency experience under the CBD curriculum will offer a unique experience in resident driven learning and assessment. This should have a positive effect on your ability to self-assess and continuing professional development – positive features of a job applicant.

 

7) I don't want to be a guinea pig...

You won't be. You’re all VIPs. All Queen’s programs have been working collaboratively and very hard to ensure you will be well supported on entering residency in July.

 

8) Some helpful links with more information:

 

Royal College Website on CBME: 

http://www.royalcollege.ca/rcsite/competence-design-e

 

Royal College Website link to milestones and EPAs: 

http://www.royalcollege.ca/rcsite/documents/dialogue/dialogue-15-2-e#vol15-2-epa-milestones

 

Queen’s CBME FAQ: 

http://meds.queensu.ca/education/postgraduate/cbme/resident_resources/faqs

 

Benefits of CBME:

http://meds.queensu.ca/education/postgraduate/cbme/resident_resources/benefits

 

Postgraduate CBME website link (has some helpful videos):

http://meds.queensu.ca/education/postgraduate/cbme

 

Queen's CBME Town Hall (live recording):

https://stream.queensu.ca/Watch/Kj2m7P9R

 

Queen’s Dean on Campus blog on CBME (resident perspective):

https://meds.queensu.ca/blog/?p=3520

 

Canadian Association for Medical Education (CAME) Voice Blog (resident perspective):

http://www.came-acem.ca/pubs_CAME-VOICE-VOIX_en.php

 

CanadiEM blog on CBME (medical student perspective):

http://canadiem.org/a-medical-students-perspective-on-cbme/

 

Here is the CBME e-mail for more questions:

cbme@queensu.ca

 

Thanks for reading. Once again, if this does not answer all of your questions, please feel free to e-mail the above address, e-mail the specific program you are applying to or post on here to get more information. Best wishes and GOOD LUCK on your upcoming match!

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  • 3 weeks later...

If a preceptor or staff doesn't like a resident, is it possible for them to hold them back under the pretense of inadequate performance?

 

Who is assessing the competencies of the residents? I imagine it's the staff/attendings at the specific institution - would this not introduce bias depending on how well a resident is liked or disliked?

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If a preceptor or staff doesn't like a resident, is it possible for them to hold them back under the pretense of inadequate performance?

 

Who is assessing the competencies of the residents? I imagine it's the staff/attendings at the specific institution - would this not introduce bias depending on how well a resident is liked or disliked?

That's no different than the current system (pre-CBME). You are still evaluated by staff. The major difference now is the competencies are much better laid out and documented.

 

Before they could say: we think you are a weak resident and should be put on probation (or held back or whatever). There would be some documentation but not a ton.

 

My understanding of CBME is the competencies are much better laid out and documented. So it's much clearer earlier on if you aren't meeting the standard. I think it'll be helpful for people in the end.

 

Also, promotion decisions are based on a panel opinion in my experience, not one person. It would be very difficult for one person with a vendetta for you to hold you back inapproriately.

 

Full disclosure: I'm basing this off my residency/fellowship and my exposure to CBME planning which started during my time as a resident at my program. I never trained under CBME. I am not associated with Queens and did no training there.

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That's no different than the current system (pre-CBME). You are still evaluated by staff. The major difference now is the competencies are much better laid out and documented.

 

Before they could say: we think you are a weak resident and should be put on probation (or held back or whatever). There would be some documentation but not a ton.

 

My understanding of CBME is the competencies are much better laid out and documented. So it's much clearer earlier on if you aren't meeting the standard. I think it'll be helpful for people in the end.

 

Also, promotion decisions are based on a panel opinion in my experience, not one person. It would be very difficult for one person with a vendetta for you to hold you back inapproriately.

 

Full disclosure: I'm basing this off my residency/fellowship and my exposure to CBME planning which started during my time as a resident at my program. I never trained under CBME. I am not associated with Queens and did no training there.

 

Thanks for the question, Let'sGo - I can't summarize it much better than this reply post, so I will echo what was said here. The decision to hold back a resident is not one that is taken lightly, and definitely is not made by a single staff or preceptor. The advantage to this CBME model is that clinical encounters will now be directly evaluated in a standardized fashion, rather than at the discretion of individual preceptors. In this way, areas of strength and areas of weakness can be identified early on, so that training can be tailored to each individual's strengths and weaknesses. 

 

Depending on the program in the current model, a resident may go weeks or even whole rotations without having a clinical encounter directly evaluated. In the specific case of a struggling resident, this makes it difficult for a staff physician to say "you need to improve in X and Y" without actually observing that resident doing those things. This means that problems can snowball when they are not addressed early on and only come to light late in residency when practice changes are much more difficult to make. In the new model, that assessment is formalized and the staff physician can engage more fully in a discussion. This is not only true in the case of weaknesses - often residents' strengths go unnoticed as well. 

 

To answer your specific question about staff who simply don't "like" you - one staff with a vendetta cannot necessarily hold a resident back under the pretense of poor performance any more than they could now.

 

To answer your other question about who is assessing the competencies - it is direct observation mostly by staff but also senior residents/fellows. Could this introduce bias? There would not be any more bias than there could possibly be under the current model. I think you will find that staff having a vendetta against residents is really quite rare, and there are institutions in place at the post-grad medical education level to address any concerns in that area.

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  • 2 weeks later...

How frequently will students be assessed? What kind of assessments will they get? Are staff trained in these "competency" assessments? 

 

One criticism I've heard is the potential for assessment overload, and potentially getting in the way of clinical duties. This shift in education dogma may be difficult for staff, and may find the frequent assessments to be tedious. 

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  • 3 weeks later...

How will salaries work under competency based medical education? 

Sorry this took me so long to get back to you - have been away for a while. Salaries will be unchanged for this upcoming group of residents because, as mentioned, the time frame to complete residency isn't likely to change. Hope that answers things! I will try to log on more frequently to answer anything else.

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How frequently will students be assessed? What kind of assessments will they get? Are staff trained in these "competency" assessments? 

 

One criticism I've heard is the potential for assessment overload, and potentially getting in the way of clinical duties. This shift in education dogma may be difficult for staff, and may find the frequent assessments to be tedious. 

 

All great points and excellent questions! 

I see you asked this question a while ago, sorry for the late response. I also see you are in the Schulich 2020 class (great school, btw :P). So I will try to answer your questions with the caveat that in three years when you start, things will likely look a lot different.

 

1) Frequency of assessments will vary by program. That is the short answer. Once or twice a week is a reasonable estimate (that does NOT mean big formal assessments necessarily)

 

2) The type of assessments are anything from a complete observed history and physical to something more specific and less time consuming like being assessed delivering news to a patient, performing a cranial nerve exam or taking a history. The point is that we often get taught the theory of many of these minor aspects of becoming a doctor but rarely or never get assessed actually doing them in the real life setting. CBME is aiming to change that. If that doesn't fully answer your questions, DM me and we can chat.

 

3) Short answer, yes. These "competency" assessments are usually no different than any other type of assessment. Speaking for Queen's specifically, our staff in all departments are getting information on how this should look. Obviously, getting everybody on board is a challenge, and will be for any program, but the culture around Queen's seems to be very much on board with this change.

 

The criticism in your second part of the post is a great point. We are doing our best to mitigate the feedback fatigue by making these assessments short, goal directed and recordable at the point of care on a smartphone, tablet or computer. That is, the assessments and tracking of it can be done with a 1-2 minute debrief session so it shouldn't cut too much into clinical duties or take up too much time.

 

Hope that answers your questions! Again, if I am deducing your grad year correctly, most FRCPC specialties will be transitioned to CBME on a national level so things will likely look somewhat different than they do now.

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All great points and excellent questions! 

I see you asked this question a while ago, sorry for the late response. I also see you are in the Schulich 2020 class (great school, btw :P). So I will try to answer your questions with the caveat that in three years when you start, things will likely look a lot different.

 

1) Frequency of assessments will vary by program. That is the short answer. Once or twice a week is a reasonable estimate (that does NOT mean big formal assessments necessarily)

 

2) The type of assessments are anything from a complete observed history and physical to something more specific and less time consuming like being assessed delivering news to a patient, performing a cranial nerve exam or taking a history. The point is that we often get taught the theory of many of these minor aspects of becoming a doctor but rarely or never get assessed actually doing them in the real life setting. CBME is aiming to change that. If that doesn't fully answer your questions, DM me and we can chat.

 

3) Short answer, yes. These "competency" assessments are usually no different than any other type of assessment. Speaking for Queen's specifically, our staff in all departments are getting information on how this should look. Obviously, getting everybody on board is a challenge, and will be for any program, but the culture around Queen's seems to be very much on board with this change.

 

The criticism in your second part of the post is a great point. We are doing our best to mitigate the feedback fatigue by making these assessments short, goal directed and recordable at the point of care on a smartphone, tablet or computer. That is, the assessments and tracking of it can be done with a 1-2 minute debrief session so it shouldn't cut too much into clinical duties or take up too much time.

 

Hope that answers your questions! Again, if I am deducing your grad year correctly, most FRCPC specialties will be transitioned to CBME on a national level so things will likely look somewhat different than they do now.

Thank you!

 

My other question is, I'm not sure if this has been asked.

 

Will electives be tailored to their specific specialty? Residents often complain that off service rotations are totally useless, and it doesn't have to be that way. Maybe some of our senior subscribers who are residents could comment on this, as I don't want to over generalize. One could learn about the aspects of the off service rotation that is pertinent to their specialty.  

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  • 3 weeks later...

Thank you!

 

My other question is, I'm not sure if this has been asked.

 

Will electives be tailored to their specific specialty? Residents often complain that off service rotations are totally useless, and it doesn't have to be that way. Maybe some of our senior subscribers who are residents could comment on this, as I don't want to over generalize. One could learn about the aspects of the off service rotation that is pertinent to their specialty.  

 

Hi Again,

 

I cannot comment specifically for each specialty, because each one is creating their own curriculum. That being said, the overall goal is to have everything that a resident does prepare them to be the best they can in that specialty - and that includes elective time. Sorry I can't give a more definite answer there.

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  • 3 weeks later...

If a preceptor or staff doesn't like a resident, is it possible for them to hold them back under the pretense of inadequate performance?

 

Who is assessing the competencies of the residents? I imagine it's the staff/attendings at the specific institution - would this not introduce bias depending on how well a resident is liked or disliked?

To take it a step further, what avenues are there to assess the assessor?

That is, if CBME will have more frequent evaluations of a resident by a staff, will there be just as much opportunity to evaluate the staff? 

 

CBME is predicated by the notion that a staff is of high quality.  I know strong residency programs will thrive under CBME. But I worry about programs where there is variable quality in their staff. 

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