CBME for PG Training
CBME - An Understanding
We can think of Competency-Based Medical Education as a flexible, lifelong learning, experience with knowledge and/or skills acquired and assessed throughout the process. In a competency-based educational program, you don’t just acquire knowledge and then spit it back at the time of a final exam; instead, you are evaluated on how you apply your knowledge to clinical situations. While University exams play an important role in gauging levels of knowledge, it is the formative assessments with focused feedback for improvement and self-directed learning which are central to the lifelong learning process.
CBME is a learner-centred, active learning experience that emphasizes learners achieving desired, predetermined program outcomes to improve healthcare outcomes of the population/ society.
The concept of competency-based training began when industry and businesses started researching ways to teach their employees the specific knowledge and skills needed to perform their job in a standardized manner. The decline in traditional standards of education has sparked a demand for minimum standards and performance competencies to be met by the outgoing students to ensure gainful employment.
Competency Definition and Statement of Competencies:
“Competence is defined as the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities being served.” 2
The Competency-based system of education uses the following steps:
- The desired outcomes are identified in advance
- The level of performance for each competency are defined and spelt out clearly
- A framework for assessing competencies exists and is used
- The program is evaluated on a continuous basis to make sure that the desired outcomes are being achieved
In 1999, the Accreditation Council for Graduate Medical Education (ACGME) endorsed six domains of core competencies, towards CBME.
The six aCGME Core Competencies are:
- Patient Care
- Medical Knowledge
- Interpersonal and Communication Skills
- Practice-Based Learning and Improvement
- Systems-Based Practice
Practice-Based Learning and Improvement:
The medical field is constantly evolving. Through patient care, the practising physician is exposed to new information and innovations on daily basis: an unknown symptom or clinical sign observed, a fresh perspective on the disease/treatment process evolving from a study, etc. Practice-based learning allows busy physicians to gain knowledge in the midst of daily medical practice and helps them to apply that knowledge to real-life situations. Hence it is both efficient and effective.
The Competency of Practice-Based Learning and Improvement refers to the ability of the learner to comprehend relevant information and a commitment to lifelong learning. The PBLI sub-competencies are
- Locate, appraise, and assimilate evidence from various sources related to patients’ health problems.
- Demonstrate ability to reflect and pursue self-directed learning to improve the Quality of Care.
To maintain this Competency, physicians must develop or employ a systematic method to analyse and understand their personal practice experience.
Logbooks, portfolios, Journaling, learning from CME programs, MOOC- related activities and assessments can all be helpful in allowing the learner to identify areas of proficiency and facets for improvement.
PBLI is an essential skill set for residents and physicians, helping them develop the mindset of lifelong learning and continuous improvement through real-world observations, reflective practice and appraisal of scientific data. PBLI prompts continuous improvement of medical practice and translates into creating, more capable and better qualified physicians, significantly improving patient care outcomes.
Patient Care and Procedural Skills:
The ACGME Core Competency of Patient Care and Procedural Skills highlights the necessity of physicians maintaining a patient-centered approach to health care. The resident will meet all the requirements for this competency when he/she is able to demonstrate an ability to listen and absorb medical history, diagnose, inform, educate, prescribe & perform necessary procedures in a way that maximizes patient well being.
The Patient Care and Procedural Skills competency outlines the knowledge, skills, and attributes that to provide quality care that is effective, family- centered, compassionate, and encourages the overall health of the patient and is appropriate to their level of training. It is demonstrated by an ability to:
- Gather essential and accurate information about the patient
- Counsel patients and family members
- Make informed diagnostic and therapeutic decisions
- Prescribe and perform essential medical procedures
- Provide effective care management, maintenance of health and prevention guidance.
This competency speaks directly on how physicians should interact directly with the patients under their care, making learning of these skills a priority.
Systems-Based Practice is often seen as a relatively abstract concept for residents to master. Whereas most of the other core competencies reflect what happens as a physician interacts with patients on a day-to-day basis, this core competency focuses on the foundations/ core structure of a good medical practice: safety and quality in health care, advocacy, health care economics,
transitions of care, different types health care systems, patient centred care and chronic care. All of these diverse facets of medical practice operate by systems. In fact, it is safe to say that good systems can make a medical practice, while bad systems can certainly break one.
Health care does not exist in a vacuum; as soon as residents graduate, they will be participate in the health care system in the real world: work in hospitals, operate under government regulations, deal with health insurance and more. From the moment a physician makes an appointment with a new patient, he or she is participating in Systems-Based Practice. Therefore, residents must be aware of the health care systems in which they will operate and have the ability to provide high-quality, cost-effective medical care in the context of those systems and their available resources.
Systems-Based Practice can be broken down into sub-competencies include the resident’s ability to:
- Work effectively in various health care delivery settings relevant to their
- clinical specialty
- Coordinate patient care within the health care system they work
- Incorporate considerations of cost awareness and risk/benefit analysis in patient care
- Advocate for quality patient care and optimal patient care outcomes
- Work in inter professional teams to enhance patient safety and improve quality of care
- Participate in identification of system errors and assist implementation potential solutions.
The sub-competencies of Systems-Based Practice make up the full picture of how a resident must learn to incorporate systems into their practice and also learn how to operate within (and perhaps even improve) the health care system in general. Residents must develop systems thinking; that is, they must understand how parts of the system relate to the whole: how the system works, and how it can work better, with the ultimate goal of fewer errors and better performance. Using systems thinking, residents will approach problems with a goal of fixing the underlying system that causes the problem, not just creating a workaround that solves the problem at hand.
Although Systems-Based Practice is sometimes seen as esoteric and challenging competency to teach and to learn, it is an essential piece of medical
training. At its heart, it is a simple concept: that in the case of many injuries and medical errors, the system is often at fault, and by fixing the system, these errors and injuries can be decreased or even eradicated. Residents must recognize that their role as physician within the health care system carries a responsibility to the wider world. It is not simply about the patient or the problem in front of them; rather, it is about how a physician can understand, navigate, and improve the system. Understanding the system and their role in it will enable residents to seek out ways to change the system for the better, resulting in improved safety and health care for the population.
Medicine is constantly evolving, and even a seasoned physician with years of experience hasn’t “seen it all.” A desire for and an understanding of the need for a lifelong-learning approach to the practice of medicine is a requisite attribute of a physician to provide quality health care.
The Medical Knowledge can be broken down into the skills and attributes that comprise of resident’s ability to demonstrate:
- An analytical approach to clinical problem solving and knowledge acquisition
- Apply medical knowledge to clinical situations and
- An ability to teach others
Medical Knowledge seeks to ensure that residents are trained to continually investigate, question, and seek new knowledge. But knowledge without application is fruitless. Sharing the best practices learnt with team members and employing that knowledge in the diagnosis and treatment of patients is equally important. Medical knowledge is where all medical education begins; and, it never ends. Residents must understand that the continual process of, questioning, exploring, reflecting and learning is integral to what makes physicians successful, and contributes to the growth and improvement of the health care field as a whole.
Interpersonal and Communication Skills:
To successfully master the ACGME Core Competency of Interpersonal and Communication Skills, a resident physician needs to demonstrate the ability to effectively exchange information with patients, their families, and professional associates.
Effective communication is a two-way street. It requires the resident to be both an active listener as well as a clear, articulate speaker. The ability to receive information is as important as the ability to transmit it to others. To do this, physicians must develop meaningful relationships with their patients and their families, other medical professionals and the health care team members they interact with on a daily basis.
The Interpersonal and Communication Skills core competency is demonstrated by a resident’s ability to:
- Create and sustain a therapeutic relationship with patients and their families
- Work effectively as a member or leader of a health care team
Effective communication skills must extend beyond the patient to include the totality of the health care team. This begins with assuming the proper role in the team, either as a contributing member or as the leader. The resident will communicate respectfully with all other team members, providing constructive written and verbal feedback as required. When leading a team, the resident must facilitate discussions and provide direction. Residents should willingly share their expertise with other physicians, health related agencies, or professional groups through professional consultation.
Maintaining accurate and comprehensive medical records is also a key component to mastering the communication core competency skill. Notes and correspondence must be legible and clear, using correct grammar and spelling to prevent misunderstanding. Residents should be willing to adopt technological improvements that optimize the sharing of information between providers, departments, and medical groups.
Resident physicians do not operate in a vacuum. Interpersonal and communication skills are a combination of both verbal and nonverbal interactions with the people a resident works with and treats. Combining interpersonal & communication skills with accurate record keeping ensures that the information communicated throughout the treatment process is comprehensive, appropriate, and timely. The effective transmission of information results in better understanding, fewer errors, and ultimately a higher quality of medical care for the patients.
As the culmination of the ACGME Core Competencies, Professionalism speaks of the attitude and behavior of the resident physician. The expectation from all medical professionals is that they will treat all people with respect, compassion, and dignity; Patient needs will supersede their self-interest; and they accept and understand that they are accountable not only to the patient but also to their colleagues and society as a whole.
Professionalism can be broken down into a demonstration of the following attitudes and behaviors required of the physician as such as:
- Professional Conduct and Accountability
- Humanism and Cultural Proficiency and
- Ability to maintain Emotional, Physical & Mental Health, and
- Pursuing Continuous Personal and Professional Growth
Professionalism highlights a requirement for residents to conduct themselves as medical professionals at all times. This includes presenting themselves in a manner befitting the role of a societal caregiver, placing the needs of others above their own, striving to improve their knowledge and skills, accepting responsibility for their actions, treating all people with respect & dignity, and exhibiting an attitude of altruism & advocacy towards the welfare of patients and their families.
Professionalism also means professional growth and demands that a resident will hold fast to the desire for a lifelong-learning approach to the practice of medicine — long after their initial medical training has concluded.
Regular attendance at conferences, active enhancement of medical knowledge, and a positive response to constructive criticism are necessary to continue personal and professional growth in the health care field throughout a physician’s career.
Whether a physician is in the initial phases of their medical training or a seasoned provider, the following principles should consistently be present:
- A thirst for new knowledge
- A dedication to patients and their families
- A commitment to using scientific principles to analyse, diagnose, and develop treatment plans
- A respectful and professional demeanor in all interactions
The Competencies framework provides a way to reinforce the behaviours, attitudes, and skill sets of trainees, so that they can consistently provide quality care. The shift to CBME is an important transition that allows residents to be active agents of their own learning.