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Réexamen de la proposition de valeur de la formation médicale axée sur les compétences

The adoption of competency-based medical education (CBME) by Canadian postgraduate training programs has created a storm of excitement and controversy. Implementing the system-wide Competency by Design (CBD) project initiated by the Royal College of Physicians & Surgeons of Canada (RCPSC), is an ambitious transformative change challenge. Not surprisingly, tensions have arisen across the country around the theoretical underpinnings of CBME and the practicalities of implementation, resulting in calls for evidence justifying its value. Assumptions have been made on both sides of the argument contributing to an atmosphere of unhealthy protection of the status quo, premature conclusions of CBME’s worth, and an oversimplification of risks and costs to participants. We feel that a renewed effort to find a shared vision of medical education and the true value proposition of CBME is required to recreate a growth-oriented mindset. Also, the aspirational assertion of a direct link between CBME and improved patient outcomes requires deferral until further implementation and study has occurred. However, we perceive more concrete and immediate value of CBME arises from the societal contract physicians have, the connection to maintaining self-regulation, and the potential customization of training for learners.L’adoption de la formation médicale axée sur les compétences (FMAC) dans les programmes canadiens d’études postdoctorales a suscité une tempête d’enthousiasme et de controverse. La mise en œuvre à l’échelle du système du projet Compétence par conception (CPC), lancé par le Collège royal des médecins et chirurgiens du Canada (CRMCC), pose le défi d’un changement ambitieux et transformateur. Il n’est pas surprenant que des tensions soient apparues dans tout le pays autour des fondements théoriques de la FMAC et des aspects pratiques de sa mise en œuvre, donnant lieu à des demandes de preuves pour démontrer sa valeur.1 Détracteurs et partisans ont avancé des suppositions, contribuant à un climat malsain de protection du statu quo, à des conclusions prématurées sur la valeur de la FMAC et à une simplification exagérée des risques et des coûts pour les participants. Nous estimons qu’un effort pour retrouver une vision commune de l’éducation médicale et une proposition sérieuse quant à la valeur de la FMAC sont de mise afin de restaurer une attitude orientée vers l’avancement. De plus, il conviendrait de s’abstenir d’affirmer l’existence d’un lien direct entre la FMAC et l’amélioration des résultats pour les patients en attendant qu’une mise en oeuvre plus étendue et que de la recherche plus approfondie aient eu lieu. Cependant, on peut observer dans la FMAC une valeur concrète et immédiate découlant de la présence d’un engagement des médecins envers la société, de son orientation vers le maintien de l’autorégulation et de la personnalisation potentielle de la formation pour les apprenants

The development of national entrustable professional activities to inform the training and assessment of public health and preventative medicine residents

Background: Entrustable Professional Activities (EPAs) have emerged to bridge the gap between the learning of individual competencies and competence in real world practice. EPAs capture the critical core work of a discipline integrating competencies from multiple domains. This report describes the development of a set of EPAs for specialty training in Public Health and Preventive Medicine (PHPM) in Canada.Methods: The PHPM EPAs were developed using multiple existing sources. A combination of workshops and a national online survey was used to consult with PHPM program directors, the national specialty committee, and competency-based education experts.Results: A national survey of PHPM program directors had a 71% response rate with 80% or more of respondents agreeing with all of the 20 EPA titles and all but one of their descriptions. Competency developmental stage-specific milestones were identified for each EPA.Conclusion: The identification of the EPAs and their milestones will increase emphasis on the demonstrated performance of the specialty's core work.  Simulations applicable to several EPAs have been developed. The EPAs have also been incorporated into a PHPM National Review Course and will be used to develop a national PHPM curriculum, as well as a national written practice examination

Reclaiming physician identity: It’s time to integrate ‘Doctor as Person’ into the CanMEDS framework

In 1996, the Royal College of Physicians & Surgeons of Canada (RCPSC) adopted the CanMEDS framework with seven key roles: medical expert, communicator, collaborator, health advocate, manager, professional, and scholar. For many years, CanMEDS has been recognized around the world for defining what patients need from their physicians. From the start, the RCPSC acknowledged that these roles should  evolve over time to continue to meet patient and societal needs (updates in 2005 & 2015).  We propose that  an 8th role is now needed in the framework: “Doctor as Person”. Interestingly, this role was present in the foundational work through the Educating Future Physicians for Ontario (EFPO) project that the RCPSC drew upon in creating CanMEDS more than 20 years ago. Given today’s challenges of providing care in an increasingly stressed Canadian healthcare system, physicians are struggling more than ever with health and wellness, burnout, and the deterioration of the clinical environment. From the patient perspective, there is growing concern that physician-patient interactions are becoming increasingly impersonal and decreasingly patient-centered. The crack emerging in the foundation of physician identity needs to be remedied. We need to pay close attention to how we define ourselves as physicians, by better identifying the competencies required to navigate the personal and professional challenges we face. Only in so doing can we ward off the threat that exists in losing authentic human to human care interactions. Formalizing Doctor as Person as an 8th role in the CanMEDS framework will help patients and physicians create the space to have essential conversations about the humanity of medical care.&nbsp

Developing Academic Advisors and Competence Committees members: A community approach to developing CBME faculty leaders

Introduction: Implementing competency-based medical education (CBME) at the institutional level poses many challenges including having to rapidly enable faculty to be facilitators and champions of a new curriculum which utilizes feedback, coaching, and models of programmatic assessment. This study presents the necessary competencies required for Academic Advisors (AA) and Competence Committee (CC) members, as identified in the literature and as perceived by faculty members at Queen’s University. Methods: This study integrated a review of available literature (n=26) yielding competencies that were reviewed by the authors followed by an external review consisting of CBME experts (n=5). These approved competencies were used in a cross-sectional community consultation survey distributed one year before (n=83) and one year after transitioning to CBME (n=144). Findings: Our newly identified competencies are a useful template for other institutions. Academic Advisor competencies focused on mentoring and coaching, whereas Competence Committee member’s competencies focused on integrating assessments and institutional policies. Competency discrepancies between stakeholder groups existing before the transition had disappeared in the post-implementation sample. Conclusions: We found value in taking an active community-based approach to developing and validating faculty leader competencies sooner rather than later when transitioning to CBME. The evolution of Competence Committees members and Academic Advisors requires the investment of specialized professional development and the sustained engagement of a collaborative community with shared concerns

Delivering on the promise of competency based medical education – an institutional approach

The Royal College of Physicians and Surgeons of Canada (RCPSC) adopted a plan to transform, over a seven-year horizon (2014-2021), residency education across all specialties to competency-based medical education (CBME) curriculum models. The RCPSC plan recommended implementing a more responsive and accountable training model with four discrete stages of training, explicit, specialty specific entrustable professional activities, with associated milestones, and a programmatic approach to assessment across residency education. Embracing this vision, the leadership at Queen’s University (in Kingston, Ontario, Canada) applied for and was granted special permission by the RCPSC to embark on an accelerated institutional path. Over a three-year period, Queen’s took CBME from concept to reality through the development and implementation of acomprehensive strategic plan. This perspective paper describes Queen’s University’s approach of creating a shared institutional vision, outlines the process of developing a centralized CBME executive team and twenty-nine CBME program teams, and summarizes proactive measures to ensure program readiness for launch. In so doing, Queen’s created a community of support and CBME expertise that reinforces shared values including fostering co-production, cultivating responsive leadership, emphasizing diffusion of innovation, and adopting a systems-based approach to transformative change.

Competency-based simulation assessment of resuscitation skills in emergency medicine postgraduate trainees – a Canadian multi-centred study

Background: The use of high-fidelity simulation is emerging as a desirable method for competency-based assessment in postgraduate medical education. We aimed to demonstrate the feasibility and validity of a multi-centre simulation-based Objective Structured Clinical Examination (OSCE) of resuscitation competence with Canadian Emergency Medicine (EM) trainees.Method: EM postgraduate trainees (n=98) from five Canadian academic centres participated in a high fidelity, 3-station simulation-based OSCE.  Expert panels of three emergency physicians evaluated trainee performances at each centre using the Queen’s Simulation Assessment Tool (QSAT).  Intraclass correlation coefficients were used to measure the inter-rater reliability, and analysis of variance was used to measure the discriminatory validity of each scenario.  A fully crossed generalizability study was also conducted for each examination centre.   Results: Inter-rater reliability in four of the five centres was strong with a median absolute intraclass correlation coefficient (ICC) across centres and scenarios of 0.89 [0.65-0.97]. Discriminatory validity was also strong (p < 0.001 for scenarios 1 and 3; p < 0.05 for scenario 2). Generalizability studies found significant variations at two of the study centres.Conclusions: This study demonstrates the successful pilot administration of a multi-centre, 3-station simulation-based OSCE for the assessment of resuscitation competence in post-graduate Emergency Medicine trainees