Thursday, April 23, 2009

Competency Based Training in Medical Education

Australian Medical Council - competency based training workshop
Sydney 21 April 2009

This week I participated in a workshop with the Australian Medical Council (AMC) that to consider the degree to which competency based training is currently used and how it could be used to improve medical education across the continuum from undergraduate to continuing professional development for those practicing independently.

There is considerable momentum behind the move toward Competency Based Training (CBT). Consumers have long held the view that medical education needs to focus on the broader notion of what it means to be competent and that consumers have a role in developing the standards.

The AMC is to be commended for bringing together such a variety of professionals who have expertise and interests in developing the education of medical professionals. The participants were described by Ian Frank, CEO of the AMC, to be "everybody who is anybody in medical education". There were around 75 participants as well as AMC staff who made it all happen. They included medical schools, state and commonwealth health departments, medical students association, medical boards, and representatives of Colleges, (including CEOs, Presidents, Past Presidents and Chief Examiners). And one consumer representative (me).

The AMC convened a plenary session during which three speakers focussed on different elements. Professor David Prideaux, Profession of Medical Education at Flinders Medical School, Prof Royce Sadler, Professor of Higher Education at Griffith University and expertise in formative assessment and learning and Peter White, CEO of Royal Australian and New Zealand College of Obstetricians and Gynaecologists. I think there was scope to include the consumer perspective of competence in this section and I know a number of consumer advocates who could have contributed to this session. I would encourage the AMC to be more inclusive of consumers and the consumer perspective in workshops such as this one.

Prof Prideaux referred to Lawrence Stenhouse’s work from the 1970s in which four functions of education were identified: training (skills and procedure); instruction (facts and protocols); induction (thinking and reasoning) and initiation (professional milieu, or the vibe). CBT fits well with the functions of training and instruction. You can define the skills, procedures and facts, then test the level of attainment with a range of reliable and valid assessment tools. CBT does not work well to measure the functions of induction and initiation. An outcomes approach needs to be developed for these.

Professor Sadler reflected on the political and historical roots of CBT and how competence is a word people warm to but is not easy to define. He also spoke about the difficulty in determining the appropriate degree of specificity. If the list of competencies is too atomistic they can lose sight of what you are trying to achieve: competent doctors.

I found that there is a reasonable degree of common ground between doctors and consumers on what competency means: that a doctor is safe to practice independently and that they possess the insight to reflect on their practice and know when they have reached the limit of their expertise and knowledge. The difficulty is in defining the technical aspects of competence in such a way that the explicitly refer to the holistic view of competency. There was emphasis placed on the need to take a holistic view of competence rather than reduce this to the specific elements. These broad attributes and competencies can be articulated but there is significant difficulty in assessing and determining the degree to which competencies have been acquired. Prof Prideaux spoke about the need to get terminology right. Competency based training works best at the macro level and warned against reducing competency to small chunks. While the more specific the skills the more easily they can be measured you run the significant risk of losing the big picture and the degree to which the trainee or practitioner has attained the global competencies. To date undergraduate medical education has managed to fend off the move to the technical competencies with a focus on inquiry learning, case studies, patient centered authentic learning and development of clinical reasoning.

One of the concerns participants expressed strongly was the potential for CMT to reduce the amount of time it takes to complete the training to become a doctor. The push for CBT it seems is from government who see that reduction in the time spent in training may alleviate the workforce shortage issues. There seems to be agreement in the profession that this is not necessarily the best thing for the quality of doctors. Doctors work off pattern recognition and by seeing lots of clinical cases they develop the ability to recognise symptoms. Their concern is that a reduction in the time taken to complete the training may compromise their level of experience.

Take away messages

  • There is a need to get the terminology right and to define what is meant by competence, a competent practitioner and competency based training
  • There is a preference for a program of assessment rather a number of high stakes tests. This could include progress testing, clinical reasoning, work based assessment and global rating of students by experienced clinicians.
  • Educational panaceas come and go. In the enthusiasm (and pressure) to adopt CBT do not lose sight of the big picture: medical education needs to deliver to the profession and the public people who are competent in doing what they are trained for.

The debate is an excellent opportunity to look at what medical education is all about. Consumers need to be involved with this and I would encourage Colleges and the AMC to engage with the consumer movement.

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