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Competency Based Medical Education (CBME) at Queen's - an Update

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This is an update to a previous post from last year's CaRMS match. I have provided the same information as last year, while including some information from our experience implementing it this last year. As many of you may know, Queen's implemented Competence By Design (CBD - the Canadian CBME curriculum) on an accelerated timeline. All first year residents in July 2017, in all Queen’s programs, started on the CBD curriculum. Residents will continue on that program in 2018. 

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 nationally, as Competence By Design is being introduced in those specialties across Canada. Many of you have already or will soon see an e-mail from the departments you are applying to with similar information.

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 and throughout the application process.

*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:

- 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) After one year, how have things gone so far (information paraphrased from current CBME residents)?

Overall, CBD has been implemented with success. Residents enjoy the more frequent, varied and high-quality assessment, as well as the earlier detection if certain skills are not being developed. Residents in most specialties note that most staff have been very enthusiastic about the change, and that there is an atmosphere that allows for open and receptive communication regarding residents' experiences with CBME  Non-CBME residents in upper years have also enjoyed the increased opportunities to provide education. Surgical residents have noticed an increased focus on residency education.

As with any transition, there have been some struggles. The time constraints of maintaining an OR schedule and ward rounds have made assessments during working hours difficult for some surgical residents. This has been mitigated by developing creative solutions, including retroactive assessments. Other challenges include technical problems that our dedicated information technology support team continues to improve upon as they arise.  

Here is the CBME e-mail for more questions:

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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