Competency Based Medical Education

Competency Based Medical Education (CBME) continues to evolve and gain ground1.  It represents a move away from an over-emphasis on the generic subjects such as physiology and pathology.  When initially proposed by the WHO in 1978, it was hoped that it would concentrate medical education on the health care needs of countries. The WHO defined CBME as follows ‘the intended output of a competency based programme is a health professional who can practice medicine at a defined level of proficiency, in accord with local conditions, to meet local demands2 There had been realization for some time that medical students at the end of their training were unprepared for the role as a hospital resident.  Medical Education, which had been based on the Flexner Report (1910), is now over 100 years old and is insufficient for modern care.  The new challenges include the diverse and age population, evidence-based practice, quality improvement, and operating systems.  There needs to be a new balance that reduces the emphasis on knowledge at the expense of skills and attitudes.

In the era of accountability, society and governing bodies are demanding better assurance that the medical education system is producing competent doctors.  After the early years of medical school, most education takes place with real patients in clinical settings. Until the advent of CMBE most education programmes were organized around the time a learner spent on a defined rotation or module.  Time was accepted as a surrogate marker of competence.  This ‘passive process’ is considered outdated.

CMBE is based on the principle of being able ‘to do the job’.  It is the application of the scientific knowledge and clinical skills that the student has ascertained. It places a premium on both educational and clinical outcomes.  The competencies are derived from the needs of patients, organized into a coherent guiding framework. The ability to take a history, elicit a physical sign, perform and interpret an ECG, do a lumbar puncture, writing accurate prescriptions, and conveying a diagnosis to a patient are typical examples. Good communication skills with patients and colleagues are now one of the pillars of good medical practice. The new direction included professionalism and systems-based practice.  The aspiration was to make to make the patient’s journey through the healthcare system as effective and comfortable as possible.  The RCPI has embraced CMBE as a core principal.

The first major hurdle was how best to assess competencies.  Work-based assessments are central to the competency approach.  The evaluations must be continuous and frequent.  The role of the coach is to observe, assess, and guide.  Assessment sends out the message that skills are important.  Some of the common tools are portfolios, patient reviews, chart reviews, simulation, 360 evaluation.  The process helps to identify the gap between the trainee’s performance and the desired outcome.

At the outset there were disagreements on many aspects of the roll-out.  Some critics have suggested that CBME leads to reductionism.  Also that it may be too concerned with training to a minimum standard rather promoting excellence. The competency sequence is as follows: knows, knows how (competence), shows how (performance), does (action).  With time, practice, and experience the status of the doctor goes through novice, advanced beginner, competent, proficient, expert.

Over time it has become accepted that they can be assembled like building blocks.  The competency, such as the insertion of a chest drain, can be observed and the doctor’s skill confirmed.  It is less clear how many times a trainee needs to perform a particular task before he can be deemed safe to undertake it without supervision.  CBME can identify at an early stage the trainee who is struggling and requires remedial action.  There is a relationship between the complexity of the procedure and the time needed to acquire full competence.  In the case of neonatal intubation it is estimated that it requires 40 cases in order to achieve full competence.  Achieving competency in craft specialties such as surgery, anaesthesia, obstetrics is more challenging since the introduction of the EWTD shorter working hours.

Another issue is that medical students and trainees do not achieve competencies at the same rate.  Some take longer than others.  In recognition of this observation, there is a de-emphasis on time-based training.   Taken to its conclusion this would lead to time-variable transitions from training to clinical practice.  A move away from ‘one size fits all’ would place new pressures on training programmes.    Another problem of a flexible system would be that students would not all pass out together.  This would put a great strain on hospitals as they expect a steady, predicable en masse stream of interns each July.  One solution is to allow sufficient time within the modules in order that all students will be competent by the completion of undergraduate training.  This introduces the concept of a basic time minimum and maximum for progression.  In other words, the model of competency-based, timed rotations3.

CBME has as its broad objective an integration of knowledge, skills, and behaviours in clinical practice.  It is an evolution from the era when training was a time-based apprenticeship.  CBME is more ‘hands on’ in terms of teaching and assessing competencies.  It is more time-consuming and it requires more input by senior staff.  It needs additional resources to be launched effectively.  The gain is a more competent, professional doctor.  CBME does not end with graduation from a training programme, it should continue throughout the physician’s career.

JFA Murphy

1 Powell DE, Carraccio C. Towards competency-based medical education. N Engl J Med 2018;378:3-5
2 McGaghie WC, Miller GE, Sajid WA, Telder TV. Competency based curriculum development in medical education.  Switzerland 1978.
3 Competency-based medical education. The Royal College of Physicians and and Surgeons of Canada. 2011.