The Movement Toward Competency-Based Medical Education

In the past twenty years, there has been push within the academic medicine community for the development of a competency-based approach for reforming medical education in the United States [1]. This movement has been slowly gaining popularity since 1999 when the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) proposed a set of six core competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) that could be used to create a new framework for evaluating graduate medical education programs [1,2]. This proposal was known as the Outcome Project, a 10-year plan that sought to redefine medical education by developing a new model of accreditation based on defining outcomes linked to the six competencies [5].

Competency-based medical education (CBME) is an approach to medical training that is organized around competencies derived from an analysis of societal and patient needs [3]. It emphasizes flexibility and time-independent progress, and is centered on the learner [3]. CBME breaks down competencies into measurable milestones and focuses on the achievement of individual goals, which is in contrast to the conventional approach to assessment involving knowledge-based examinations [4]. CBME is recognized as a promising method of addressing specific challenges and shortcomings attributed to traditional models of medical education [3]. By focusing on the ultimate outcomes of physician performance and patient care, CBME aims to produce physicians who are able to adequately address the needs of the populations and communities they serve [4].

Several studies have demonstrated the educational and clinical benefits of competency-based medical education frameworks [4]. The implementation of CBME in regard to central venous catheter insertion at Mercy Hospital and Medical Center led to improved procedural skills in residents and a decline in central line-associated bloodstream infections [4]. In surgical residents, CBME approaches have been linked to improvements in clinical skills and patient care, as well as more rapid mastery of procedural skills [4]. The introduction of CBME for fourth-year medical students has also been associated with improved confidence, cognitive skills, and performance ratings in relation to the management of critical patient care tasks at the beginning of residency [4].

However, assessment of the core competencies remains a challenge that has hindered the widespread adoption of CBME [3]. Since the ACGME requires “dependable measures” to assess residents’ aptitude in the six competencies, a 2009 systematic literature review sought to evaluate the evidence about whether the six competencies could be measured independently of one another in an accurate and reliable way [5]. The peer-reviewed literature provided no evidence that current measurement tools could effectively assess the competencies [5]. Rather, all available measurement tools generally produced a single rating of overall measured competency or, sometimes, several ratings that did not directly correlate with the six core competencies [5]. The researchers concluded that it was not possible to measure the competencies independently of one another in a meaningful way [5].

Despite these difficulties, there remains a high level of support for CBME [1]. Many residency programs have already added time in their curriculum devoted to competency areas, such as interpersonal and communication skills [1]. Improvements in assessment methodologies may further increase the popularity and widespread adoption of CBME approaches and lead to education reform [1].

References 

1. Whitcomb M. (2016). Transforming Medical Education: Is Competency-Based Medical Education the Right Approach? Academic Medicine: Journal of the Association of American Medical Colleges, 91(5), 618–620. doi:10.1097/ACM.0000000000001049 

2. What Is Competency Based Medical Education? | NEJM Knowledge+. (2017). Retrieved from https://knowledgeplus.nejm.org/blog/what-is-competency-based-medical-education/ 

3. Frank, J., Snell, L., Englander, R. et al. (2017). Implementing competency-based medical education: Moving forward. Medical Teacher, 39(6), 568-573. doi:10.1080/0142159X.2017.1315069 

4. Hawkins, R., Welcher, C., Holmboe, E. et al. (2015). Implementation of competency‐based medical education: are we addressing the concerns and challenges? Medical Education, 49(11), 1086-1102. doi:10.1111/medu.12831 

5. Lurie, S., Mooney, C., & Lyness, J. (2009). Measurement of the general competencies of the accreditation council for graduate medical education: a systematic review. Academic Medicine, 84(3), 301-309. doi:10.1097/ACM.0b013e3181971f08