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Medical Training Transforms to Competency-Based Approach

By Jorge Eugenio Valdez García - School of Medicine and Health Sciences, Tec de Mty


By Jorge Valdéz | Dean - Tue, 02/28/2023 - 12:00

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Before the pandemic, medical educators were discussing competency-based education and how this influenced curriculum design, teaching methodologies and the role of teachers. The COVID-19 pandemic was a situation that took us by surprise; nobody imagined the repercussions for health and, of course, for medical education. Everything changed and the way we educate will never be the same again. Regarding postgraduate medical education, the pandemic modified the operational programs, regardless of the specialty and the health institution, due to their participation in the different COVID-19 medical care processes, which distracted them  from their original training.

The challenges now are enormous, the return to classrooms and hospitals has not been easy, the conditions among faculties and in hospitals cannot be what they were pre-pandemic. However, we must continue to adapt to new circumstances to keep training better specialists. Clinical practice is a cornerstone in the teaching of medicine. Some educational innovations, such as training in simulated environments and the use of technology, helped us to complement clinical education; however, to achieve quality clinical training, it is necessary to combine several elements, such as the incorporation of doctors into training on the day-to-day healthcare activities of a hospital, seeking the total integration of residents in the clinical activities of the service and giving academic life to medical care through actions that allow  the achievement of the competencies of the specialty.

At the postgraduate level of studies, also known as medical specialty programs, the aim is to train doctors in a clinical specialization; therefore, the programs are closely intertwined with the culture of their professional context. Progressively, physicians experience more complexity and responsibility under the supervision of tutors and institutions approved for such purposes. For this approach to be feasible, institutions rely on their educational management strategies to plan, organize, lead, and control their process.

The goal of all graduate medical education is to ensure that the graduating physician is competent to practice in his or her chosen field of medicine. To better ensure that new physicians have the competencies they need, its necessary to transform the current approach of specialist training, which specifies a fixed number of years in training, to a competency-based training, in which each resident remains in training until they are shown to have the required knowledge and skills and can apply them independently. 

Such programs, in addition to tailoring the training time to everyone, would make it possible to evaluate competency more accurately than is now possible. Traditionally, a residents' competency has been measured by the certifying opinion of the program director that the trainee is ready to practice independently, after a fixed number of years in training. The current system assumes that the more time a learner spends on an activity, the more the learner absorbs and excels. This may be supplemented by required examinations during training and is expected to be supported by successful completion of a specialty board examination. 

While our system continues to produce excellent physicians, evidence suggests that our methods of training and lifelong learning can be improved. How do people learn and how do they translate what they learn into practice? Theories of education are much neglected in our residency system. Over time, the demands on, and expectations of, specialists have changed significantly. But the medical education system has remained relatively unchanged over the past 100 years.

To ensure medical specialists are prepared to deliver the best care possible within our system that continues to evolve rapidly, we need to work with medical education to design and implement a cutting-edge approach to 21st century specialty training.

There is a global movement known as competency-based medical education (CBME), which  is led by the medical education community. The objective of CBME is to ensure physicians graduate with the competencies required to meet local health needs. It aims to enhance patient care by improving learning and assessment in residency.

Competency-based medical education for each training program asks the question, “What abilities do physicians need at each stage of their career?” It organizes physician training around these desired outcomes and looks at the needed competencies. It is logical that the major goals of competency-based training for residents must be first to define the skills and knowledge that are required for each specialty and then to prove that these attributes have been acquired and can be applied to individual patients independently by the clinician in a competent manner. 

A major focus of the CBME curriculum is on providing consistent, detailed, and timely resident feedback and assessment at each stage of training. Central to CBME is a new concept of Entrustable Professional Activities (EPAs). These are tasks that physicians (residents and seasoned clinicians) do every day. 

Certification of competency replaces the time-honored years-in-place method of residency training. Although limits might be set for minimal and maximal times for training, numbers of years in training should become irrelevant to the educational process for residents. Completion of required years of training does not assure the public of competency.

The medical education system is a contributor to the healthcare system: it is responsible for preparing the specialists to participate by providing highly specialized care.  To remain accountable to society, the medical education system must work to ensure that every graduate is competent and prepared for practice. Today’s physicians are required to operate in a system that is facing many modern pressures that did not exist when the current training system was developed. New demands are emerging, owing to the increased complexity of the society that the system serves. It’s our responsibility as medical educators to respond to these demands and challenges.

Photo by:   Jorge Eugenio Valdez García

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