Developing flexible, competency-based pathways

Medical education at all levels—undergraduate, graduate and continuing—is shifting away from emphasizing time spent in lectures and in classrooms and toward establishing that the necessary knowledge and skills have been acquired for transition to residency and patient care.

Medical schools are incorporating milestones and entrustable professional activities (EPAs) into the curriculum to determine the best path for students to follow in order to move to the next level of training.

These flexible, competency-based pathways create physicians who continually assess and update their abilities and address any deficiencies throughout their careers.

"The competencies that our students need to have when they graduate from our medical schools are going to really be quite dramatically different than they were 50 or 100 years ago when medical school was structured."

Marc Triola, MD, principal investigator/associate dean, ed. informatics, NYU School of Med

This Innovations in Medical Education webinar focused on “Competency-based assessment across the medical education continuum.” Competency-based medical education (CBME) requires a vigorous and multidimensional assessment system. In order to successfully implement CBME, assessment processes must be continuous and frequent, criterion-based, developmental, and work-based where possible.

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In this manuscript, the authors perform a root-cause analysis to determine the underlying reasons for continued norm-referencing in the context of the movement toward competency-based medical education (CBME). The root-cause analysis consisted of two processes: (1) identification of potential causes and effects organized into a fishbone diagram and (2) identification of the five whys. The authors argue that the implied purpose of assessment in UME is primarily stratification for residency selection. Because stratification requires comparison, a norm-referenced approach is needed. To advance CBME, the authors recommend reconsideration of the approach to assessment in UME to maintain the purpose of selection while also advancing the purpose of rendering a competency decision.

This narrative review examines several programs' clinical competency committee (CCC) processes and reviews the relevant literature to propose enhancements to CCCs. The authors recommend that all CCCs fulfill three core goals, regularly applied to every GME trainee: (1) discern and describe the resident’s developmental status to individualize education, (2) determine readiness for unsupervised practice, and (3) foster self-assessment ability.

This paper explores how to operationalize the entrustment process at 10 schools participating in an Association of American Medical Colleges pilot evaluating the feasibility of explicitly teaching and assessing 13 Core Entrustable Professional Activities for Entering Residency (CEPAER). Guiding principles developed by the group recommend that formal, summative entrustment decisions in undergraduate medical education be made by a trained group, be based on longitudinal performance assessments from multiple assessors and incorporate day-to-day entrustment judgments by workplace supervisors.

This paper describes a conceptual framework for entrustment to better prepare all educators involved in entrustment decision making in undergraduate medical education (UME). This framework applies to faculty with limited or longitudinal contact with medical students and to those who contribute to entrustment development or render summative entrustment decisions. The authors also differentiate between the UME learning environment and the graduate medical education learning environment to highlight distinct challenges and opportunities for faculty development in UME settings.