CBME and Time: An Inconvenient Truth

By: George Shorten

“All we have to decide is what to do with the time that is given us.”  – J.R.R. Tolkien

The idea of competency-based medical education is deeply comforting. Those who will care for us when we are ill will do so … well. Of course, if I read that as I feel a fever coming on, or as I enter hospital on a trolley or holding my unconscious mother’s hand, I would like to understand “well” a little better. My assumption is that a team of professionals with the optimal skills, are provided with the information they need to formulate and carry out a plan that ensures that I am (or my mother is) well cared for. There’s that tricky word again – “well”. As I consider what well looks like, my attention is drawn to the many elements that (I imagine) make up quality of care: drugs, procedures, diagnostics, judgement, compassion (and lots of other stuff that I don’t understand), the extent to which these interact, and their likely influence on my (my mother’s) outcome. But people are central to how reassured I feel   – doctors are the conductors of the healthcare orchestra, and my team will be competent because they have been trained to be competent. Even if I were to pause to consider what competent means, or how it is measured, or against what standard, its attribution to those looking after me is deeply comforting. These doctors are the “products” of competency based medical education (CBME).

But there is the crux: much healthcare depends on rational `thinking applied using a sound foundation of empiric evidence. CBME is heavy on rigorous rationale but light on high quality evidence. The underlying principles are undeniable; the challenge is to achieve education and training that results in good care which is delivered consistently and sustainably. Only when that happens will the potential that CBME offers be realised. But delivery, consistency, and sustainability are all functions of time. Their achievement requires that we move from internal to external validity, from proof of concept to generalisability, and from efficacy to impact. For this, we require the mundane and understated benefits of implementation science.

The Greeks used two words for time: “chronos” for the measurable passage from moment to another, “kairos” for those unmeasured moments when the world appear to stop as we experience intensely. Much CBME discourse describes a state or circumstance which is effectively timeless. It describes a systems at particular points in time. The doctor has achieved competence …. To anchor such a desirable state in the real world requires that we understand and deal with the passage of time and its effects on competence. This is “chronos”, the inconvenient, costly and erosive sort of time.

After several decades of commitment, investment and constructive effort to effect CBME, one might reasonably enquire as to how much health gain has been achieved. The frameworks, accreditation and faculty development programmes, assessment tools, and much else has been meticulously put in place. But, to quote Drs Bauer and Kirchner1, Everything went right. What went wrong?

Here are some questions which, in 2022, remain uncomfortably unanswered:

Assuming any combination of determinants of learning other than time, how long does it take to acquire the knowledge, skills or attitudes commensurate with being a good doctor? (For this purpose, determinants might be as diverse as Long Term Potentiation of CA1 in the hippocampus, timely and highly informative feedback, learning style, casemix and volume, “readiness” to learn, and motivation).

Assuming any combination of determinants other than time, when does skill attrition occur?

Over the course of a career in medicine, what time-related factors determine whether a doctor performs well or poorly?2

How should a doctor’s scope of practice change or diminish over time?

Over what time scale should an effective educational intervention in medical education deliver measurable health gain? (It is frequently stated that it takes an average of 17 years for biomedical research evidence to reach clinical practice)3-5.

Currently, I believe that the answers to each of these questions are “I don’t know” or “it depends”. And of course, the absence of definitive answers does not imply that CBME is not worthwhile – it is.

But the implications are:

  1. that time must feature more in the primary objectives of CBME research and evaluation and in the accreditation of CBME programmes (continuous vs intermittent).
  2. research into CBME should include adaptive designs6 and prioritize study of interventions/models which can be scaled and transferred.
  3. the implementation science of CBME requires further attention, in particular the time function in intentional organisational change.

About the author: George Shorten, FRCA FFARCS(I) DABA MD PhD DSc, is Professor of Anaesthesia and Intensive Care Medicine and Foundation Director of the ASSERT Centre at University College Cork, Ireland as well as the President of the College of Anaesthesiologists in Ireland.

References

1. Bauer MS, J Kirchner. Implementation science: What is it and why should I care? Psychiatry Res. 2020;283:112376.

2. Dellinge EP, CA Pellegrini, TH Gallagher. The Aging Physician and the Medical Profession: A Review. JAMA Surg. 2017; 152(10): 967-971.

3. Westfall J, J Mold, L Fagnan. Practice-based research–“Blue Highways” on the NIH roadmap. JAMA. 2007;297(4):403-6.

4. Trochim W. Translation Won’t Happen Without Dissemination and Implementation: Some Measurement and Evaluation Issues. 3rd Annual Conference on the Science of Dissemination and Implementation. Bethesda, MD: 2010.

5. Green L, J Ottoson, C Garcı´a, R Hiatt. Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annu Rev Public Health. 2009;30:151 –74.

6. Pallmann  P, AW Bedding, B Choodari-Oskooei et al. Adaptive designs in clinical trials: why use them, and how to run and report them. BMC Med 2018;16(1):29

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