By: Dan Schumacher (@DrDanSchumacher)
I have noticed that many people, even those responsible for aspects of competency-based medical education (CBME) implementation and maintenance, have trouble succinctly defining CBME. My experiences were confirmed in a recent well-done paper by Sherbino and colleagues, who described tensions in describing CBME among key Canadian opinion leaders.1
I only need two words to define CBME – patient-focused and learner-centered. For me, every important tenet of CBME maps to one of these two words. As I survey CBME programs around the world, I think most people believe CBME is a learner-centered approach to medical education, even if they do not explicitly use that word to define CBME. However, there seems to be more heterogeneity about whether people believe CBME is a patient-focused approach to medical education. This perplexes me. In this blog, I will explore both components of my definition of CBME to detail why I believe both pieces are foundational to what CBME seeks to achieve.
As detailed eloquently in a landmark piece in Lancet2, the design of traditional structure- and process-based medical education begins with defining a curriculum. While it is hoped that this curriculum will prepare trainees to meet the needs of patients, that is not guaranteed. Rather, the curriculum often bends to the interests and desires of those creating it and is prone to, as Stephen Abrahamson quipped in 1978, “diseases” that include ossification (unwillingness to change the curriculum), hypertrophy (adding more and more to the curriculum), and carcinoma (uncontrolled growth of part of the curriculum).3 Once a curriculum is defined, the traditional approach to medical education defines educational objectives for the curriculum and then assesses learners on how how well those objectives are met in their learning. The patient and what they need is included in this approach in one of only two ways: 1) the curriculum developers ensure that, or 2) happenstance.
CBME turns this model on its head, starting with the end in mind and defining the training/educational outcomes necessary to provide the care that populations of patients need. With CBME, what patients need comes first. From there, requisite competencies and outcomes to meet those needs are defined. Only then are curricula aimed at developing those competencies and ensuring those outcomes developed. In turn, assessment efforts seek to ensure those competencies and outcomes are achieved. Note that assessment is just part of CBME as I describe it here. Too often, CBME is thought of solely as a new approach to assessment. It is not. It is a new approach to medical education entirely. CBME requires a fresh look at curricula as much as assessment efforts.
Learner-centeredness is a more widely recognized characteristic of CBME. This component of my CBME definition was beautifully detailed in a landmark 2002 article by Carraccio and colleagues.4 In this article, the authors offer several comparisons of structure- and process-based education (traditional approach) and CBME, highlighting the role of the learner. Some of the comparisons they make include:
- Driving force of the curriculum: In a traditional approach, content (or knowledge application) is most important for a learner to demonstrate. However, in CBME outcome (or knowledge application) is prioritized.
- Driving force for the learning process: The teacher is the driver in a traditional approach; whereas, the learner is in the driver’s seat in CBME.
- Responsibility for the content: In a traditional approach, the teacher has responsibility for the content. As noted above, this can lead to their interests dominating the curriculum more than they should. In CBME, teachers and trainees share the responsibility for what is learned. Trainees should be given agency, choice, and autonomy in what and how they learn to the extent possible.
- Focus of assessment: In a traditional approach, norm-referencing is the focus. Learners are compared to one another to determine who is better and who is not as good. In CBME, criterion-referencing is the focus. Given that the goal is to ensure learners achieve the outcomes needed to provide the care that patients need, everyone could achieve that outcome, no one could achieve that outcome, or any number of individuals between none and all could achieve that outcome. Again, CBME is patient-focused. The goal is to ensure that everyone entrusted to provide unsupervised care is capable of doing so. Criterion referencing should shift focus from competition between learners to collaboration where “best” is defined as the goal of a master adaptive learner developing themselves to be their personal best rather than comparing themselves to others and trying to be #1 on a list where everyone else follows them.
- Timing of assessment: In a traditional approach, summative assessment aimed at making overall judgments about performance is the primary focus. While CBME employs summative assessment, it places a primary focus on formative assessment that helps learners understand where they are in their development and help them take next steps.
Patient-focused and learner-centered. The definition of CBME is as simple as two words – albeit two words that pack a lot of details about the foundation and design of CBME. What is more important than learners and patients in medical education? I would argue nothing. This is why I believe CBME is our best path forward for designing our education efforts.
About the author: Daniel Schumacher, MD, PhD, MEd is Director of the Education Research Unit at Cincinnati Children’s Hospital Medical Center and a tenured associate professor in the University of Cincinnati’s Department of Pediatrics.
1.Sherbino J, Regehr G, Dore K, Ginsburg S. Tensions in describing competency-based medical education: a study of Canadian key opinion leaders. Adv Health Sci Educ Theory Pract. 2021;26(4):1277-1289.
2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. Dec 4 2010;376(9756):1923-58.
3. Abrahamson S. Diseases of the Curriculum. Academic Medicine. 1978;53(12):951-957.
4. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting Paradigms: From Flexner to Competencies. Academic Medicine. 2002;77(5):361-7.
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