By: Elaine van Melle (@elainevanmelle) and Eric Holmboe (@boedudley)
“Starting with the end in mind” is a key principle of competency-based medical education (CBME).1 Practically speaking, this means identifying and using the competencies required to meet patient and community needs as the basis for the training of all physicians.2 Makes sense, right? Medical education should center on meeting patient and community needs. But then what?
Enter the Core Components Framework (CCF).3
Developed as an organizing framework, the CCF describes a comprehensive CBME curriculum as having five core components.
- Outcome-based competencies
- Progressive sequencing
- Tailored learning experiences
- Competency-focused instruction
- Programmatic assessment
As already stated, determining outcome-based competencies provides an important starting point. The second component, ‘progressive sequencing’, makes it clear that acquiring these competencies is a developmental process. So we need to provide teachers and learners with a clear road map. This means for example, using Entrustable Professional Activities (EPAs) and/or milestones and/or stages of learning, to describe learner’s developmental trajectories and create a path of progression. A path however, that allows for considerable individual flexibility in progression. Indeed, mastery learning, a foundational concept underlying CBME,4 encourages a uniform, high level of performance while allowing for variation in time to completion amongst learners.5 With outcome-based competencies clearly specified and progressively sequenced, we can now turn to designing the curriculum.
A curriculum is made up of learning experiences, instructional methods and assessment practices. These are captured in the last three core components.
Component 3 – Tailored learning experiences require a flexible curriculum that allows learners to advance at their own pace. A curriculum map, where learning experiences are mapped onto competencies, is a key tool. This map is used to ensure that all learners have the opportunity to develop the required competencies. By including ample opportunity for direct observation, learners can receive specific feedback and guidance on their progression. Armed with this feedback, learners can adapt and co-produce6 their learning experiences to meet their specific needs and pace. The inclusion of personal learning plans can be a powerful tool to support this process.
It’s not hard to see why CBME requires learners to co-produce and direct their own learning. Teachers however, also play a very important role. This is captured in Component 4 – Competency-focused instruction. In CBME, teaching is individualized to the learner. As coaches, teachers provide the critical feedback to learners and work with learners to co-produce individualized learning plans. Competency-focused instruction, therefore, requires providing teachers with the tools and processes that allow for high quality and accurate assessments and feedback.
Most of us are familiar with the phrase “assessment drives learning” so it may seem a bit strange that assessment appears as the fifth and final component of the CCF. The key is in the word ‘programmatic’. In Component 5 – Programmatic assessment challenges us to shift away from finding the perfect tool, to seeing assessment as a system of decision-making; a system that relies on multiple sources of input as we track learner progression over time. In CBME this tends to be the function of a Clinical Competence Committee (CCC). A CCC however, that truly supports progressive development of competencies, relies on instructors who provide high quality feedback and engaged learners who can effectively direct and co-produce their own learning and assessment.7 All components therefore are seen to work together and be equally important.
About the authors:
Eric Holmboe, MD. is Chief of Research, Milestones Development and Evaluation Officer at the ACGME, as well as Adjunct Professor of Medicine at Yale University, the Uniformed Services University of the Health Sciences, and the Northwestern University Feinberg School of Medicine.
ELAINE VAN MELLE, PhD, is the Education Research and Program Evaluation Specialist in the DEPARTMENT OF FAMILY MEDICINE at Queen’s University, as well as Education Scientist at Royal College of Physicians and Surgeons of Canada.
1.Harden RM. Outcomes-based education: Part 1 – An introduction to outcomes based education. Med Teach. 2009; 21:7-14.
2. Frenk et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923-1958.
3. Van Melle E et al. A core components framework for evaluating implementation of competency-based education. Acad Med. 2019;94:1002-1009.
4. McGaghie WC et al. Competency-based Curriculum Development in Medical Education: An Introduction. Geneva, Switzerland: World Health Organization; 1978.
5. McGaghie WC. Mastery learning: It is time for medical education to join the 21st century. Acad Med. 2015;90:1438-1441.
6. Englander R et al. Coproducing health professions education: A prerequisite to coproducing health care services? Acad Med. 2020;95:1006-1013.
7. Hauer KE et al. Reviewing residents’ competence: A qualitative study of the role of clinical competence committees in performance assessment. Acad Med. 2015;90:1084-1092.
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