Residents, supervisors move toward CBME

New approach 'just makes educational sense,' says associate dean, postgraduate medical education

By Sasha Roeder Mah

Competency-based medical education (CBME) began gaining traction as a preferred method of resident training about eight years ago, when the College of Family Physicians of Canada made a gradual introduction of the methodology to family medicine residents nationwide. The University of Alberta's Faculty of Medicine & Dentistry Postgraduate Medical Education program is now part of the broader national shift to CBME, and last year began with two programs: Anesthesiology and Otolaryngology. Six more have since been added.

CBME is based on a better understanding of how people learn. "In the past, curricula have been written in the form of objectives, using very traditional educational language," says Ramona Kearney, Associate Dean, Postgraduate Medical Education.

While the vast majority of residents have proceeded smoothly through their rotations under the traditional model, about 15 per cent needed a bit of extra support to succeed, says
Kearney. And those people were often slipping through cracks in the system. "They were struggling, not passing their rotations, with no one telling them exactly what they need to change" and suddenly being told, after four years of building bad habits, they weren't going to be successful. "That's something we really wanted to change."

"Just because you put a person in a situation for a certain amount of time, doesn't mean they're going to learn what they need to," says Kearney. "When you understand how people learn, you say, 'How could this not be better?' It just makes educational sense. We're not throwing time out the door, but now 'three months of pediatric anesthesia' does not necessarily mean you're good to go. Some of you can finish in two months, some of you may need four."

You may imagine that the most important difference between traditional time-based residency training and CBME involves a move away from rigid time limits for the completion of rotations. But that's only a small piece of what's changed, explains Kearney.

In the traditional approach to resident training, a supervisor assumes that all graduates come with a common toolkit of abilities. "So as soon as they arrive, you'll give them a task, and they'll go off and do it." The new approach critiques whether that's a fair way to train for success.

"They're not cookie-cutter people; they all have strengths and weaknesses in different areas," says Kearney. With CBME, residents are given the chance to first work through a task with their supervisor, who observes and gives constructive feedback before sending them out to work alone with patients. "In terms of psychological safety as a learner, you're not being put into a situation you've not been in before, so you should have more confidence in what you're doing," says Kearney.

Frequent observations of daily workplace events and situations- toward achieving revised outcomes called entrustable professional activities-continue throughout the residency. Before CBME, a resident might go through a two-month rotation and receive feedback twice. And that feedback might have either been friendly but unhelpful ("You're fun to work with") or ​negative but too general ("You need to read more"). Now, with the help of an app, residents complete an electronic self-assessment at the end of every shift and share it with their supervisor, who will input their own feedback and assessment

Supervisors are being taught to teach and assess differently. They proceed through a series of training modules, developed in partnership with the Faculty Development office. They begin with a broad introduction to the concept of CBME and work through more specific skill development such as how to educate using a coaching model.

Another benefit of CBME is that no one supervisor has to make a pass or fail decision on a resident's performance, which can be challenging for the supervisor and threaten the teacher-learner relationship. "There's no end-of-rotation evaluation now," says Kearney. Instead, assessments are collected from the app, submitted to a portfolio and shared at least four times a year with a competence committee, who then meet with the resident's academic adviser to determine the resident's readiness to move on.

Kearney has already seen powerful evidence of the effectiveness of CBME. Last year, at the very first four-month competence committee meeting, it was clear that a resident was struggling, she recalls. "That would not have happened in the old system, probably not until second year. That was early detection as a direct result of daily feedback, and from that, they were able to make an educational plan for that resident. This is an amazing improvement."