Royal College’s Competence by Design Initiative Launched July 1st for First-Year Psychiatry Residents

04 August 2020

It’s known as Competence by Design (CBD), and it’s aimed at reforming and enhancing the training of all medical specialists in Canada.

Launched by the Royal College of Physicians and Surgeons of Canada in 2017, CBD is based on a global movement to improve patient care by establishing standardized systems and metrics to better monitor the learning and assessment of Residents.

More than half of all medical specialty training programs in Canada have already adopted the CBD approach, and the remainder are expected to do so over the next couple of years.

As a first step, the Department of Psychiatry’s Resident Program launched the CBD initiative for first-year (PGY-1) Residents effective July 1st, with plans to roll it out sequentially for PGY-2 through PGY-5 Residents in subsequent years.

“In essence, CBD is a process to ensure that Residents are actually being observed in the development of their skills. It requires supervisors to provide timely feedback and have it documented periodically throughout the training process,” says Dr. Roger Brown, Associate Program Director, Psychiatry Resident Program, and Chair of the Department of Psychiatry’s newly formed Competence Committee.

“That’s really the biggest difference. Previously, Residents would be evaluated at the end of a rotation, which might last a month or six months, when feedback is less helpful. Although our Residents likely got feedback all the way along, under the new CBD system, we’ll have more substantive proof of that.”

Under the CBD initiative, the Royal College’s Specialty Committees have organized each specialty program into four distinct stages of training. At each stage, Residents are given a list of specific learning objectives – known as Entrustable Professional Activities, or EPAs – and each Resident must be observed completing each EPA.

Supervisors record their EPA observations and related feedback in an electronic portfolio, which the Resident is able to review. At regular intervals throughout each stage of training, the Competence Committee – comprised of seven Faculty members from the Department of Psychiatry – reviews the documented material.

The committee then provides a recommendation to the Residency Training Committee on whether the Resident can progress to the next stage of training. That allows any gaps in learning to be identified and addressed before the next stage of training starts.

“The basic idea with CBD is that there will be more observational data being collected on each Resident’s progress,” says Erica Osko, who was appointed CBD Coordinator for the Psychiatry Resident Program in April.

“In addition, decisions on their learning status and promotion won’t be left to an individual reviewer who fills out an evaluation. It’s up to a committee of medical educators, which will review the Residents and monitor their progress on an ongoing basis.”

By implementing CBD, the Royal College exam becomes only one of many assessment points for Residents. Specialty committees will also have the power to move the Royal College exam ahead, to the end of stage three, thus allowing Residents to focus more intensely in the final stage of training on their transition to practice.

By shifting the responsibility for a Resident’s assessment and potential advancement to a committee, the CBD approach also aims to depersonalize the review process.

“Sometimes it’s difficult for a supervisor to tell a Resident that your performance isn’t quite where we want it to be, and that you aren’t successful in this particular rotation. It’s a lot easier for a committee to deliver that message than it might be for an individual supervisor, so that’s certainly another important change,” says Dr. Brown.

The process to form decisions about advancement and promotion also become more objective with CBD, he adds, since they’ll be based principally on performance data as opposed personal feelings. “The impressions or feelings that someone might have toward a Resident aren’t actually relevant to these decisions, so hopefully it means that better decisions will be made.”

Besides Dr. Brown, other voting members of the Competence Committee include Dr. Katharine (Kate) Hibbard, Associate Director of the Resident Program; Dr. Erin Will, a Forensic Psychiatrist and Clinical Lecturer in the Department of Psychiatry; Dr. Lovneet Hayer, an Addictions specialist and Clinical Lecturer; Neuropsychiatry specialist Dr. Sarah Tymchuk; and Dr. David LeBaron, a Clinical Lecturer.

Resident Program Director Dr. Tania Oommen attends all Competence Committee meetings in a non-voting capacity.

“Since CBD was implemented in 2017, I think the feedback overall has been positive. It has helped to ensure that trainees are performing the skills that they need to have,” says Dr. Brown.

“It perhaps has made the job of administering a Residency Program and the job of being a Resident a bit more laborious, since there is more data to sort through. When there’s more data someone has to look at the data and you need processes to ensure it’s being examined properly, all of which requires an investment of time,” he notes.

“For some supervisors in the initial stages it might be a bit more onerous, but I think it will become routine fairly quickly. I’m very pleased so far with the reception from the supervisors who are involved with the first-year Residents. There has been almost universal enthusiasm and a willingness to make this work and I see that reflected in the evaluations that have been done since July 1st. They’re getting on board in a way that I was hoping for but wasn’t necessarily expecting.”