Associate Dean's Message

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CBME: Risk and Reward

Efforts at transformative change succeed when perceived rewards outweigh perceived risks. My ongoing Competency Based Medical Education (CBME) conversations with faculty, residents, and staff have helped me to appreciate both what people are excited and confident about and what they are worried and skeptical about. Putting both the risks and the rewards of CBME on the table for scrutiny is essential; the risks, in particular, require   mitigation strategies if we are to move forward together.  Three risks deserve particular attention:

RISK: Faculty Burnout

Even if faculty buy in to the educational benefits of CBME, they may perceive that CBME demands of them a larger time commitment, particularly for resident assessment.  Direct observation with feedback, for example, is fundamental to CBME; making it happen means creating opportunities that may not be part of the usual organization of clinical work. 

Observation, though, needn’t be constant and needn’t always be lengthy. Targeted observation of focused activities can be done with limited disruption to clinical activities; our early adopter specialties are proving that, and our Family Medicine colleagues have shown that brief field notes can be incorporated into the way clinical work is done without sacrificing efficiency. 

We need to consider what faculty can stop doing as well as what they need to start doing. Engaging faculty in brief, targeted, observation-based assessments may be more palatable if we can also relieve them of the need to complete lengthy evaluation forms at the end of each block.

RISK: Reductionism

CBME fits comfortably with tasks we can readily observe, like procedures. But what about those critical clinical tasks that are harder to observe, like clinical reasoning and judgment?  Even more challenging are those fundamental but ineffable qualities of good doctors – humanity, compassion, empathy.  If we aren’t careful, we risk limiting our CBME approaches to those tasks we can readily observe.   We risk reducing the complex, holistic performance of good doctors to a series of check boxes that focus on the things we can easily see.

Specialty committees are a first line of defense against this kind of reductionism. When they meet to hammer out what it means to be a specialist in a particular discipline in the 21st century, they need to embrace the spirit of CanMEDS, whose greatest contribution to medical education may be serving as a reminder that medical expertise draws on multiple roles. Locally, we need to continue to emphasize professionalism, communication, collaboration, advocacy, scholarship, and leadership in the way we design our curricula and our assessment strategies, and in the learning culture we establish for our learners.

RISK: Lost Opportunities

CBME implementation efforts rightly concentrate on curriculum planning, coaching for learning, and assessment of learner performance. We must get each of these elements right. But CBME is more than an implementation challenge; it is also an opportunity to learn about the impact of educational change on learning and health care outcomes. The logistics of implementing CBME in the moment risk consuming all our educational oxygen. But without a concurrent plan to critically evaluate what we are implementing, we’ll lose our opportunity to advance the science of medical education. 

A common question I’m asked by faculty and residents when I talk about CBME is “what’s the evidence?” For the most part, the answer is that there isn’t any evidence, although the educational theory underpinning CBME is sound.  We have an obligation, therefore, to build the evidence base – to understand what works and what doesn’t, to fine-tune and adjust strategies that are underperforming, and to ask crucial questions about the differences our educational approaches are making to the health of our populations.

CBME’s risks shouldn’t stop us. If we approach them with eyes wide open, we’ll ensure a stronger future for our residency programs, and better health care for our communities.