Paper's Podcast theme collection: Competency Based Education (CBE)

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Jason Frank: Welcome back to the Papers Podcast. It’s Jason with you, and today I have a consult. As you know, we’re supposed to be in this competency-based education era, and we have been asked at the podcast… What exactly do we mean by competency-based education and what does a program look like if it’s competency-based? So I guess you could title this episode, Is This Program Competency-Based?

And what I’ll do in this consult is I’ll briefly introduce you to some of the terms that are related to competency-based education. I’ll talk about the origins in a very brief way of this movement. I’ll try and define things for you. And I’m going to help you with some key Papers that will guide you and help you decide whether or not a program is truly competency-based.

So if you go to any health professions education conference, if you open any issue of any of the journals, if you hear abstracts presented, you can’t help but notice that people use the phrase competency-based education or CBE. Sometimes they make it a bit more specific to one profession, like CBME for medicine, CBVE for veterinary medicine.

Competency-based nursing and so on it’s been applied to more than a dozen health professions now around the so when someone’s talking about that they it’s kind of a throwaway word it’s almost like a given like everybody in the room understands what we mean but it’s actually confusing because there are times where i’m sitting in the audience and this is my area of scholarly focus and i think to myself is that really competency-based what do they mean by that so first of all where did all of this conversation, this discourse about competency-based education began.

And there are some who have looked at the literature and they look at higher education, competency-based vocational education and training, for example, or teacher education. And some authors have traced it back to 1910. I like to start the health professions version of that conversation in 1978. That was the year that McGehee and colleagues produced a seminal report for the World Health Organization.

So if you just Google WHO CBME 1978, it’ll take you straight to a very grainy photocopied PDF of that paper. And so that group, that group of four authors, was asked to look at the world’s state of health professions education and make recommendations on how to improve training worldwide. And what they decided was that the world was characterized by variability in training.

And what was needed was… Some standardized approaches that really focused on outcomes. They felt like the training around the world was too focused on time spent and not enough on intention and helping graduates acquire the needed abilities. And that, my friends, is a very nice place to point to when you think about the origins of competency-based medical education.

So competency-based education in the health professions is really an approach. It has a common philosophy, more about that in a second, but it’s really an approach to design. So to say that something is competency-based implies that they’re using this approach, as opposed to that it has some feature that is always included.

So for example, if it’s competency-based, it uses EPAs. Well, not necessarily. In fact, I could dream up a couple of designs that use EPAs that wouldn’t be competency-based.

These are all tools that help us enable a competency-based approach. So let me unpack that for you in case I’ve confused you further.

So remember, we’re starting the clock at 1978, the launch of the WHO McGehee paper.

Jason Frank: And this approach slowly, slowly gained momentum and really took off at the end of the 90s, beginning of the 2000s. And now is a worldwide phenomenon where nearly every country is, as at least some institutions, using competency-based approaches for health professions, education, design.

So what were the drivers?

In the past, our design in the 20th century evolved from our ancestors, where it was very much an apprenticeship design. You were immersed in somebody’s practice. A master clinician helped you learn things until they said, you’re good enough, you can go down the road. In fact, that reflects our medieval origins, where people became journeymen in their professions.

So that’s our apprenticeship origins. And then we got a little bit more scientific with some key reports, the Flexner report, for example, and the work of the group at Johns Hopkins, including Osler and Halstead, where our 20th century model was made apprenticeship, immersion, and then incorporation of teaching science.

Over time, we evolved our systems much more standardized, some accreditation bodies around the world, but really it still had a lot of features of time-based training with master clinicians at present. The problem with that system, which we’re all very nostalgic about, it’s certainly the system I grew up in, is that our graduates are variable and that harms patients sometimes.

So if you look around the world in every specialty or health profession that we’ve looked at, you find graduate practice is variable. And graduate abilities are variable. What that means is that sometimes people graduate with lacunes, little gaps in their abilities, and often they’re filled in practice, but sometimes they’re not.

Sometimes people have relatively less competence below the threshold of what we’d want for all of our graduates, and that results in variable care provided and sometimes harm to patients. And you can find this literature around the world. You can find it in the patient safety literature, but you can find it… In all the literature that looks at variability in practice.

Why does that happen? One approach to thinking about that is that it’s because the design of the curriculum didn’t ensure that every graduate met a minimum threshold.

Now, before you start thinking that competency-based education is all about minimums, but a race to some sort of bottom threshold that everybody has to cross, that’s not the case at all. Excellence is still quite consistent with a competency-based approach. It’s really just ensuring that there’s no learner left behind.

Everybody is intended to leave a program prepared for the next stage of practice. So fundamentally, competency-based education is an approach. It’s a series of design decisions that are really focused on outcomes of an educational program. And in the health professions, our outcomes are our graduates and their abilities to be prepared. For the service they will provide in the next stage of their career.

So that’s how I think about competency-based education. It’s really an approach, and it’s about preparing our graduates. All right. So philosophically, underneath competency-based education are some recurring themes. One is constructivism, this idea that competence is a socially constructed phenomenon.

It is not a score on a test. It is not a reliability metric from a high-stakes exam. Competence is the ability to serve the patients in front of you. So constructivism implies that those sets of abilities are societally defined, they’re socially defined, and that is incorporated into competency-based education thinking.

Systems thinking is also a part of the CBE world. We like to think of multiple ingredients that enter into a greater whole. And when you pull on one ingredient, you move another. And so when… When you have a CBE approach to curriculum design or designing a whole system for a jurisdiction or a country, we think in systems and more about that in a minute.

So the implications of this is that you see things like expertise theory and mastery learning enter into competency-based education designs. You see designers motivated by some of these phrases, no learners left behind. Flexibility and learner-centeredness are definitely design elements.

Beginning with the end in mind, so ensuring that we really clearly defined the outcomes competencies for our graduates of a given program, and then work backwards through the ingredients needed to ensure that every graduate meets those competencies, all of them. This is a design-oriented approach.

It’s deliberate. We make deliberate choices. It’s not just we’re going to put them in this ward and we’ll prescribe them this much time. It’s not about time. Time is a resource for competency-based education. It’s really about choices of activities and learning events and sequencing.

So this has a number of implications. And if you put it all together, what you get is Elaine VanMell’s beautiful paper on the Core Components of competency-based education. So if you want to decide if a program is, quote, competency-based, have a look at Elaine VanMell’s paper, The Core Components.

It’s published in Academic Medicine in 2019 in the July issue. And Elaine VanMell is the first author. A few of the hosts from the podcast are there. John’s there as well as myself. So there’s a beautiful table.

In this paper, and it’s actually figure two, and it goes through with the five Core Components of CBER and what is underneath it. So let me walk you through that. When I think of competency-based education, and if I’m looking at any design, I actually have these five things in mind. So in this paper, we come up with that if it’s competency-based education in health professions, it has number one, outcomes competencies defined.

Number two, it has a design that is sequenced progressively. For the acquisition of competence. And number three, it has tailored learning experiences. Number four, it has competency-focused instruction. And number five, it has programmatic assessment. Those are the five key features that suggest to me that somebody is using a competency-based approach. Let me unpack them for you, and maybe that’ll help you going forward.

Number one, outcomes-focused competencies. This one actually is an essential first step, and it’s very difficult to design a competency-based education without doing this step. To do it really well involves doing a systematic needs assessment. Sometimes it’s job task analysis. What do experts in this scope of practice in this setting do? What are the abilities needed to do this well?

What will the abilities be needed going forward over the next few years or decades? So it involves also a social accountability mandate. What do patients want and need from an expert practitioner? Or somebody WHO’s really prepared to serve a given population well. It involves context. So in what setting will they work? What will be the factors?

Jason Frank: WHO will they work with? And out of that should come some statements around abilities. Competency-based education is fundamentally about defining abilities of graduates and then developing something, a series of experiences, so that every graduate can be ready for that scenario, having all of those abilities. So the number one component is outcomes competencies.

Number two is sequencing.

So this is one that I don’t see a lot of people around the world using extensively, though it’s coming on. This second component is that you use expertise theory and mastery learning. And as a designer, you make decisions to help decide what level will learners enter into this program? How can you sequence a progression of expertise through the curriculum?

And then what level do you want them to exit at? So you have to look at that outcome competency list in component one, and then you have to work from whatever level they enter. Let’s call that the novice level of whatever health professions stage a learner is in.

And then how can you actually sequence the curriculum deliberately? So here’s an example. When trainees come to my emergency department and join the emergency medicine residency program, we start them off as novices. They rotate through the emergency department and some other learning experiences. But there’s…

Level of responsibility and the things that we’re looking for from them start off small and get bigger over time. And by the time they’re ready to graduate, they’re a junior colleague already. They’re like in a junior tending. We treat them that way. We give them greater and greater responsibilities. So that’s sequencing and the design of the curriculum.

So that’s number two. And remember that one’s based on expertise theory and some ideas of mastery learning.

Number three is tailored learning experiences. So in our 20th-century design of health professions education, learning experiences were something we had a vague idea about, and then we threw people into clinical learning scenarios, and basically, based on time, they were immersed in either somebody’s practice or on a ward providing service.

Tailored learning experiences says we’re very deliberate in choosing the activities that a given learner travels through in order to ensure that all the competencies are acquired. So this implies a blueprint.

So underneath the surface of any competency-based curriculum is a blueprint that says, hey, these competencies need to be acquired and they’re going to be at this level and in this context. So they need this experience. It’s mapping. It’s mapping competencies and experiences to where they intersect. So there’s a lot of design decisions that are very deliberate choices in a competency-based approach.

Number three is competency-focused instruction. So this really is teaching. And the way that teaching is impacted by a competency-based approach is really thinking about diagnosing any given learner when you teach them or supervise them. What level are they at? What are the agreed-upon competencies I want to help them acquire?

And then really focusing all of my teaching interventions around filling that gap. Now, you may say that’s always what good teachers have done. That’s true. But this is, again, a really deliberate design choice. And it means that every teacher needs to know how they fit into that instructional blueprint. That curriculum design so they know what to focus on.

So if you’re a clerkship director or a program director or some other health professions education director, and you want your frontline teachers to practice competency-focused instruction, you need to help them connect to the blueprint that you’ve made so that every learner gets that boost, gets focused on the right stuff. And finally, programmatic assessment.

Now, this is a very popular topic. I love all of the work that Case Vandervlooten and Lambert Shulworth did to develop this concept. Programmatic assessment says it’s a system of assessment. So again, this systems type thinking. It says that just having a one-off test or a one-off retrospective workplace-based assessment, it’s not good enough in the 21st century.

We have evidence to say it’s not good enough. What’s really needed is a lot of small, low-stakes assessments that are assembled, curated, and collated. Into a systematic decision about progress. This entire approach, competency-based education, is about progress of expertise.

And programmatic assessment fits into that by providing data to the learner, to the teacher, and to those overseeing the curriculum about how a learner is progressing. This is why you see the rise of competence committees around the world in various types of design. It’s a group of people looking holistically at all the data on a given trainee.

And looking at how they’re moving from novice to the expert level that’s designated as the outcome competency and making a collective decision. Programmatic assessment says we’re going to use multiple different assessment methods. We’re going to try and do that with an emphasis on authentic settings.

So in the context that this person will in the future practice, and we’re going to do lots and lots of low stakes observations, collate them, capture them and roll them up into a very systematic decision. Programmatic assessment, an amazing advance on what generations prior, including me, experienced. I loved my teachers. They did a great job. They were very dedicated to the training programs that I was a part of.

But it was a programmatic assessment. No, it was a few pieces of paper done retrospectively a few times a year, plus one very big exam at the end.

So there you have it. That’s the five Core Components of competency-based education. I’ll just recap them to keep them in your short-term memory. Help your hippocampus and code them. So it’s outcome competencies, it’s sequence progression, it’s tailored learning experiences, it’s competency-focused instruction, and it’s programmatic assessment.

All right. So it’s an approach, it’s focused on outcomes, and it has these five Core Components. We’re talking about competency-based education in the health professions. Let’s just finish with how does that look? How would you apply this? How do you see this around you? Use this as a test as to whether or not this program is competency-based.

So for me, if you look at competency-based teaching, you see teachers using mastery learning principles. You see teachers focusing on agreed competencies and helping learners progress towards the ultimate level of those agreed competencies. If you’re looking at competency-based assessment, you see the characteristics of a program of assessment.

You see assessment that is both of learning and for learning. Data that is useful and authentic by frontline teachers WHO made direct observations, lots and lots of low stakes, little observations that roll up into decisions about progression, but in the moment can be used to help a learner get better. That’s where coaching comes in.

Competency-based curricula use all of the Core Components or as many as are practical to implement. What we are seeing around the world is that a lot of people start with outcomes competencies and programmatic assessment. And slowly start incorporating the other three components. We see that in the lots of examples around them.

And finally, what happens if you see a competency-based system? Maybe a jurisdiction is designing a system of health professions so that they produce the graduates that that society needs. What you see is that there’s defined competencies for each health profession and for each level or stage of career.

So they’re prepared. They develop their health professionals WHO are… Ready with the right abilities at the right time for the setting that they’re going to work in and for the populations they’re going to see and the kinds of problems they’re going to try and address.

So a system that is competency-based ensures that graduates are prepared with the right abilities at the right time. All right. So on the surface, competency-based education programs can look very similar to the ones that our generation all experienced, speak for myself. But when you look deeper, What you see is a lot of design decisions.

You see goals and competencies are defined, and that the teachers involved are aware of their role in those blueprints that have been made. You see activities that have been deliberately chosen to help fill gaps in competencies. And the nature of the teaching and the assessment are different than prior designs.

Competency-based education is really a revolution that’s happening around the world. You may have some experience with that, and it might have been a good experience. It might not have been a good experience. But I can tell you that worldwide, it seems to be what all of us are working on. I hope this consult helped you.

And I hope you can use it in your future work. Take care, everybody.

You’ve been listening to the Papers Podcast. We hope we made you just slightly smarter. The podcast is a production of the Unit For Teaching And Learning at the Karolinska Institutet. The executive producer today was my friend, Teresa Sörö.

The technical producer today was Samuel Lundberg. You can learn more about the Papers Podcast and contact us at www.paperspodcast.com. Thank you for listening, everybody. Thank you for all you do. Take care.