Competency-Based Medical Education
Nguyen Quang Trung, M.D.; Ph.D.
Danang, 16 October 2019
Roadmap
[Link] education system in the
USA
[Link] to CBME
[Link] of Competencies,
[Link] of EPA
[Link] of Milestones
[Link]
MEDICAL EDUCATION SYSTEM IN THE USA
MEDICAL EDUCATION
HIGH
SCHOOL
ACADEMY EDUCATION: RESEARCH, TEACHING
Ph.D.
TEACHING IN BIO-MEDICINE
(3-4 YEARS)
M.D. - Ph.D. TEACHING IN BIO-MEDICINE & PRACTICE
GRADUA (6 YEARS)
TED
FROM HS COLLEGE
(4 years) HEALTH
PROFESSIONAL EDUCATION: PRACTICIAN
CARE
WORK
BOARD EXAM
BOARD EXAM
NAT’L EXAM
INTERNSHIP
MEDICAL FELLOW FORCE
MCAT
DOCTOR RESIDENCY EDUCATION EDUCATION
3-7 YEARS DEPENDING TO SPECIALTY) (2 YEARS)
(4 YEARS)
OFFICIAL LICENSING, VALID FOR
TEMPORARY LICENSING
2 YEARS
CME/CPD (50h/y)
PRACTICE AT TRAINING SITES SPECIALY ADVANCED SPECIALY
PRACTICE PRACTICE
HEALTH CARE SYSTEM
Competency-based medical education
(CBME)
an outcomes-based approach to the design,
implementation, assessment, and evaluation of
medical education programs
an approach to preparing physicians for practice,
fundamentally organized around competencies
derived from the needs of people and societies
Frank JR et al. Competency-based medical education: theory to practice. Medical Teacher. 2010; 32: 638–645.
McGaghie WC, et al. Competency-Based Curriculum Development in Medical Education: An Introduction. Geneva, Switzerland: World Health Organization; 1978
The rationale for CBME
1. Focusing on curricular outcome
2. Emphasizing abilities (competencies as the
organizing principle of curricular)
3. De-emphasizing time-based training
4. Promoting greater learner - centredness
Frank JR et al. Competency-based medical education: theory to practice. Medical Teacher. 2010; 32: 638–645.
McGaghie WC, et al. Competency-Based Curriculum Development in Medical Education: An Introduction. Geneva, Switzerland: World Health Organization; 1978
CBME vs. Traditional Model
Variable Traditional Educational Model CBME
Driving force for curriculum Knowledge acquisition Knowledge application
Driving force for process Teacher Learner
Path of learning Hierarchal Non-hierarchal
Responsibility of content Teacher Teacher and student
Goal of educational
Knowledge acquisition Knowledge application
encounter
Single assessment measure Multiple assessment measures
Type of assessment tool
(e.g., test) (e.g., direct observation)
Authentic (mimics real
Assessment tool Proxy
profession)
In clinical and professional
Setting for evaluation Removed
settings
Timing of assessment Emphasis on summative Emphasis on formative
Program completion Fixed time Variable time
The importance of faculty development in CBME
1. Faculty development in CBME is needed,
2. Faculty needs to understand principles of
CBME to train and assess leaners in a CBME
system,
3. 3 levels of faculty development in CBME:
system level, institute level and individual
level.
Deepark et al. Importance of faculty development in Competency-based medical education. Medical Teacher. 2010; 32: 683–686.
Definition of Competency
•Competency = observable abilities of a health
professional, integrating multiple components such as
knowledge, skills, and attitudes, that develops through
stages of expertise from novice to master level,
• Competence = array of abilities across multiple domains
of physician performance in a certain context,
• Competence = The goal of an education program,
• A good curriculum provides the mechanism through
which competence is acquired.
Frank JR et al. Competency-based medical education: theory to practice. Medical
Teacher. 2010; 32: 638–645
Defining Competencies, questions to
consider
Health needs
➢ Patients, Population
➢ Society
➢ Country
➢ Current needs vs Future projected needs
➢ Other?
Practice scope
➢ When residents graduate, they will be able to independently perform/do what tasks?
➢ What scope/task will require continued training?
How do you determine above?
➢ National/Sub-national/Regional studies
➢ Patient surveys
➢ National ICD-10 codes, insurance claims
➢ Current epidemiology vs future epidemiological projections
➢ International examples/guidelines
Domains of Competencies
Steps in Planning CBME Health needs of population
curricula
Identify abilities needed of graduates (Desired outcomes)
Define competencies & their components
Define milestones along a development path
Select educational activities, experiences, and instructional methods
Select assessment tools to measure progress along the milestones
Competencies -> EPAs
COMPETENCY: general, difficult to measure/assess
ENTRUSTABLE PROFESSIONAL ACTIVITY (EPA):
• EPAs translate competencies into professional practices
• EPAs are units of professional practices, defined as
tasks or responsibilities that students are expected to
perform once they have achieved sufficient competence,
• Represent the “day-to-day” works that the student is
expected to learn and be able to do by the time of
graduation.
Competencies – EPAs Matrix
EPI 1 EPI 2 EPI 3 EPI 4 EPI 5
Competency 1 X X
Competency 2 X X
Competency 3 X X X X
Competency 4 X
Competency 5 X X X
Competency 6 X X X
Principles of EPAs
• These are responsibilities/activities that all 6 year students (at the time
of graduation) should be expected to perform without direct
supervision, regardless of specialty,
• The activities will represent a necessary set of competencies for
graduating students, a “core,” not a ceiling (students can go above and
beyond),
• Assessment of these activities must embrace qualitative feedback based
on direct observation,
• The ideal implementation and assessment system will give students
many opportunities to practice with repeated, low-stakes formative
assessments, culminating in entrustment decisions for each of the EPAs
by the time they graduate.
# of EPAs proposed, related to program
Source Programme Length (years) Number of EPAs
Mulder et al. (2010) Physician assistant education 2.5 5–8
Boyce et al. (2011) Psychiatry residency, 1st year 1 4
Jones et al. (2011) Paediatric residency 3 17
Hauer et al. (2013) General internal medicine residency 3 30
Chang et al. (2013) Internal medicine Unspecified 25
Shaughnessy et al. (2013) Family medicine residency 3 76
Developmental-behavioural paediatrics
O’Keeffe (2014) residency Unspecified 14
Englander et al. (2014) Undergraduate medical education 2.5 13
Fessler et al. (2014a,b) Pulmonary care residency 1–2 18
Fessler et al. (2014a,b) Critical care medicine residency 1–2 13
Rose et al. (2014) Gastro-intestinal fellowship 3 13
Caverzagie et al. (2015) Internal medicine residency 3 16
Undergraduate medical education pre-clerkship
Chen et al. (in press) training 2 5
Shumway et al. (2015) Haematology/oncology fellowship 2–3 5
Schultz et al. (2015) Family medicine 2 35
Entrustable Professional Activities (EPAs) for UGE
13 EPAs
EPA 1: Gather a history and perform a physical examination
EPA 2: Prioritize a differential diagnosis following a clinical encounter
EPA 3: Recommend and interpret common diagnostic and screening tests
EPA 4: Enter and discuss orders and prescriptions
EPA 5: Document a clinical encounter in the patient record
EPA 6: Provide an oral presentation of a clinical encounter
EPA 7: Form clinical questions and retrieve evidence to advance patient care
EPA 8: Give or receive a patient handover to transition care responsibility
EPA 9: Collaborate as a member of an interprofessional team
EPA 10: Recognize a patient requiring urgent or emergent care and initiate
evaluation and management
EPA 11: Obtain informed consent for tests and/or procedures
EPA 12: Perform general procedures of a physician
EPA 13: Identify system failures and contribute to a culture of safety and
improvement
Competencies->EPAs->Milestones
COMPETENCY
MILESTONE MILESTONE MILESTONE
ENTRUSTABLE PROFESSIONAL ACTIVITY (EPA) 1
MILESTONE MILESTONE MILESTONE
ENTRUSTABLE PROFESSIONAL ACTIVITY (EPA) 2
Milestones vs EPAs
Milestone = The expected ability of a health care professional at a
stage of expertise
The key difference between EPAs and milestones is that EPAs
are descriptions of professional “tasks” that a graduate must be
able to perform, whereas milestones are the abilities of the
individual, along a developmental continuum.
Using Milestones in CBME
Traditional System CBME System
Time-based: Assumption that Competency-Based:
as medical trainee moves Advancement process is based
through medical training (i.e. on milestones, and identifying
with ’more time’), they will which milestones trainees have
gain the knowledge and skills achieved, and what more they
needed need to do to achieve desired
milestones
Source: Brown, Warren, et al. Finding a Path to Entrustment in Undergraduate Medical
Education: A Progress Report from the AAMC Core Entrustable Professional Activities for
Entering Residency Entrustment Concept Group. Academic Medicine. 2017
Example
EPA 1: Gather a history and perform a physical examination
By the end of 6 years of medical education, students should be able to perform an
accurate complete or focused history and physical exam in a prioritized, organized
manner without supervision and with respect for the patient. The history and physical
examination should be tailored to the clinical situation and specific patient encounter.
This data gathering and patient interaction activity serves as the basis for clinical work
and as the building block for patient evaluation and management. Learners need to
integrate the scientific foundations of medicine with clinical reasoning skills to guide
their information gathering.
Milestones:
• Obtain a complete and accurate history in an organized fashion. (End of Year 2)
• Demonstrate patient-centered interview skills (attentive to patient verbal and
nonverbal cues, patient/family culture, social determinants of health, need for
interpretive or adaptive services; seeks conceptual context of illness; approaches the
patient holistically and demonstrates active listening skills) (End of Year 3)
• Identify pertinent history elements in common presenting situations, symptoms,
complaints, and disease states (acute and chronic) (End of Year 4)
• Demonstrate clinical reasoning in gathering focused information relevant to a patient’s
care (End of Year 4)
Competencies->EPAs->Milestones->Learning Objectives
COMPETENCY
LO LO LO LO LO LO LO LO LO
LO LO LO LO LO LO LO LO LO
MILESTONE MILESTONE MILESTONE
ENTRUSTABLE PROFESSIONAL ACTIVITY (EPA) 1
LO LO LO LO LO LO LO LO LO
LO LO LO LO LO LO LO LO LO
MILESTONE MILESTONE MILESTONE
ENTRUSTABLE PROFESSIONAL ACTIVITY (EPA) 2
Example of Competencies->EPAs-
>Milestones->Learning Objectives
FIELD 3: COMPETENCE IN MEDICAL CARE: General
practitioners shall have ability to resolve a normal demand for
medical care safely, promptly, cost-effectively based on
scientific evidence and appropriate to the real conditions.
(1854/QD-BYT)
➢ EPA 1: Gather a history and perform a physical
examination
➢Milestone 1.1: Demonstrate ability to take concise and relevant
history from patient
➢LO1.1.1: Student is able to complete a full patient history –Y2
➢LO1.1.2: Student able to incorporate chief complaint to direct relevant questions
on history –Y3
➢LO1.1.3: Student is able to disregard irrelevant history questions Y3
➢LO1.1.4: Student has good ability to do time management –Y3-4
Competencies->EPAs->Milestones-Assessment
Fitting EPAs into your curriculum
• Determine WHAT
• Remember! All students need to be fully “Entrustable” (they can
do it without direct supervision) by the time they graduate.
• Keep in Mind! EPAs are a progression, so you start in earlier
years and build up (setting milestones)
• Determine WHEN (milestones)
• By the end of year 1 – 2 – 3 – 4 – 5 – 6 … my students will be
able to…
• Determine HOW
• How will you assess?
• Mini-CEX, OSCE, Direct Observation, Feedback from Patients, Peers,
Faculty?
Review…
If a student is struggling
with an EPA, the faculty
can break the EPA
down into its
component abilities
(milestones) to help
determine where
further guidance or
teaching is needed.
Source: Royal College of Physicians and Surgeons of Canada
A Curriculum
Developer’s
guide with EPAs
and Milestones
for Entering
Residency
(AAMC)
The US Experience in EPA/Milestone
Development
• Competencies are general to all residencies, very general
• EPA and Milestones are specific to individual specialties
• ACGME brings specialties together to form national specialty working groups;
all reached consensus that there would be four required levels of milestones
for residents to reach, with Level 5 being ‘aspirational’
• Each specialty working group had ~15 members (representatives from
different groups (e.g. ACGME, specialty board/association, program directors
group, resident/fellows)
• Each working group met 3-4 times to complete the process
• Working group reported results → advisory board ‘preliminary approval’ to
share with programs for pilot and feedback → Advisory Board/Working Group
to edit → ACGME to publish
Source: ACGME Medical Education, 2016
EPAs as an Assessment Framework
• EPAs are executable, observable, and measurable in their
process and outcome, allowing the faculty and school to
determine if the student has met the milestone and competency
Direct Observation
Mini-CEX
MCQs
EPAs
Case Presentations
Student’s Portfolio
OSCE
Organizing around Competencies
(5 Principles)
1. Competencies required for practice are clearly articulated to
leadership, faculty and trainees (residents)
2. Competencies and milestones are arranged progressively
3. Learning experiences facilitate the progressive development of
competencies
4. Teaching practices promote the progressive development of
competencies
5. Assessment practices support and document the progressive
development of competencies.
Source: van Melle (personal communication) via ACGME Medical Education, 2016
Thank you for your attention
Questions?
