Competency Based Medical Education_Prof R. K. Dixit_KGMU_Lucknow

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CBME is upcoming modality of medical teaching

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Competency Based Medical Education:

Prof. R. K. Dixit Pharmacology & Therapeutics (Medical Education Unit) King George’s Medical University Lucknow dixitkumarrakesh@gmail.com Competency Based Medical Education Hind Institute of Medical Sciences, Sitapur King George’s Medical University Lucknow

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Session will focus on Definitions of Goals, Roles, Entrustable Performance (Professional) Activities (EPA), Competence & Competencies The principles of competency based medical education (CBME) Competencies developed by the Medical Council of India Redesign of medical education Differences between the current and proposed CBME What is new in proposed MCI - UG curriculum Why we all are concerned with the changes Challenges and possible solutions (Group discussion) Opportunities to facilitate alignment of educational missions

One Minute Please:

One Minute Please Q. How are stars like false teeth? A. They both come out at night!

Lets start with a jock:

Lets start with a jock An airplane full of engineering college professors is going on a trip. Before takeoff the pilot proudly announces that the plane was built by their students. Immediately everybody runs to get out of the plane Except The oldest professor. When asked why, he says he was absolutely confident That The plane won’t make it to the runway.

Bitter Truth:

This joke would not sound so funny if it is on the medical profession. How many of us medical college teachers are willing to be treated by our own students ? How many of us are willing to entrust the health and lives of our dear ones in the hands of our students? Is medical education as a system producing doctors, who can be entrusted? If not, where is the fault ? Bitter Truth

Problem Lies in :

Problem Lies in Lack of competency in all domains Lack of explicit competency based training Lack of explicit competency based assessment Focusing more on theory than the competency Ignoring the attitude and communication part Supposing that all students learn at the same pace Less interaction and less utilization of feedback

History of Medical Education in India :

History of Medical Education in India India has a rich, time tested heritage of medical science. Date to 6000year BC. Three phases Ayurveda, Unani, and Allopathic. The first books: Charaka Samhita and Sushruta Samhita The method of education during Vedic period was imparted through the system in which peoples left their homes and lived with their master (Residency Scheme) to learn the principles and practice of medicine

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Post- vedic period 600 BC to 200 AD . Ayurveda reached highest level Unani system introduced The Allopathic system Introduced in 16th century by European missionaries. Portuguese missions hospital at Calicut, Madras, and Goa Modern medical colleges started in 1824 at Kolkata, Chennai and Mumbai Recognized by the Royal College of England since 1843 Standards were of General Medical Council of Great Britain

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General Medical Council of Great Britain supervised medical education of India till 1933 In 1933 the Indian Medical Council Act was passed Medical Council of India was constituted in 1933 Medical education in India expanded phenomenally

Medical Council of India:

Medical Council of India Established in 1933-34 under the Indian Medical Council Act, 1933 Reconstituted under the Indian Medical Council Act, 1956 (Amendment) Ordinance 26/09/2018 ( Ordinance 8 of 2018), MCI will be governed by Board of Governors (BOGs) . The Council Regulates medical education of India Grants recognition of medical qualifications Gives accreditation to medical schools Grants registration to medical practitioners Monitors medical practice in India.

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Modern medical Education System started with the work of Flexner

Medical Education in NEWS:

Medical Education in NEWS

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Nasca et al. N Engl J Med 2012

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A key element is the measurement and reporting of outcomes through the educational milestones… Nasca et al. N Engl J Med 2012

Now a days CBME becomes buzzword amongst the medical education community:

Now a days CBME becomes buzzword amongst the medical education community

Why do we need CBME?:

Why do we need CBME? To be more confident of our products To emphasize an outcomes-based approach Instead of assuming CBME focuses on a reconstructed system of teaching, learning and assessment Within each of domains/stages of training, a learner can achieve a level of competence from novice to competent The construct for CBME relies on four foundations; Focusing education on community needs Emphasizing learner abilities De-emphasizing time based learning Increasing individualized trainee plans for learner

Origin of CBME- WHY?:

Origin of CBME- WHY? Aim of generating health professionals who are Scientifically trained Purposeful & Competent to cater health needs of the society Aim of decreasing gap between medical education and Health care delivered Societal health needs The curricula need to be designed towards achieving these outcome requirements steered by appropriate assessment methods. Herein lies the origin and essence of Competency-based Medical Education (CBME)

Competency-Based Medical Education:

Competency-Based Medical Education CBME is an outcomes-based approach to Design Implementation and Evaluation of a medical education program Using an organizing framework of Milestones and Competencies The International CBME Collaborators Frank et al. Med Teach , 2010

Redesign in Medical Education:

Redesign in Medical Education Competency-Based Medical Education (CBME) Focus is on outcomes Reflect health system needs Curriculum and Assessment Reform Moving towards andragogy New curricular elements Milestones, Competencies and EPA’s Regulatory Changes

Goal of Medical Education in India (Regarding Undergraduates):

Goal of Medical Education in India (Regarding Undergraduates) To produce IMG Primary contact physician Doctor of first contact Competent doctors who are globally relevant Humane doctors Professional doctors To produce IMG (first contact doctors) who are competent, humane, professional and globally relevant

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Roles of IMG (C2L2P) P rofessional L eader and member of team L ife long learner C ommunicator C linician

Paradigm Shift in Medical Education From Making Doctors to Good Competent Doctors :

Shifts from theory to practice From teacher centered to student centered From THEORY TO COMPETENCY From theory based to scenario based From h ospital to community-based From solo to team work From solo subjects to integrated learning From pieces to complete picture Changing role of the teacher From person to pass knowledge to that of a FACILITATOR Paradigm Shift in Medical Education From Making Doctors to Good Competent Doctors

Paradigm Shift in Medical Education Who are good competent doctors??:

Paradigm Shift in Medical Education Who are good competent doctors?? Doctors who - take care of patients as their primary concern -are COMPETENT -keep their knowledge and skills up to date -establish good relationships with patients and colleagues -are honest and trustworthy -act with integrity -listen to the patients’ view -can negotiate treatment plans

Paradigm Shift in Medical Education From KNOW to Able to DO??:

Paradigm Shift in Medical Education From KNOW to Able to DO?? Must Know to Must be able to DO Should Know to Should be able to Do Can Know to Can be able to Do

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Goal: A projected state of affairs that a person or system plans to achieve Desired (anticipated) results that a person or a system plans and commits to achieve Broad statements with Desired end-point Roughly similar to purpose or aim Where do you want to go? O r What do you want to become?

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Role:- A  set of connected behaviors The division of labour among heterogeneous specialized positions

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Competency: the H abitual and J udicious use of C ommunication ,   K nowledge, T echnical skills , C linical reasoning , E motions, V alues ,   and R eflection (What happened, So What, What next) in daily practice for the benefit of the individual   and community being served (Epstein & Hundert , 2002)

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Competencies serve the basis for standards that specify the level of knowledge, skills, and abilities/attitude required for success in the workplace as well as potential measurement criteria for assessing competency attainment.

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A bility to deliver a specified professional service. C orrectly perform predetermined tasks T asks (Competencies) are identified in the CBME Competency

Levels of Competency:

Levels of Competency P Performs (under supervision or independently) Mastery for the level of competence - When done under supervision a pre specified , or independently SH Shows how A skill attribute: is able to interpret / demonstrate a complex procedure requiring thought, knowledge and behaviour S Shows A skill attribute: is able to identify or demonstrate the steps KH Knows how A higher level of knowledge – is able to discuss or analyse K Knows A knowledge attribute – Usually enumerates or describes H igh er level implies that the lower levels have been acquired

“Entrustable Performance Activity (EPA) and it’s relationship with competencies:

“ Entrustable Performance Activity (EPA) and it’s relationship with competencies EPAs are the essential day-to-day activities of a profession that an individual must be trusted to perform without direct supervision EPAs require the INTEGRATION OF COMPETENCIES —across domains—and thus can be mapped to those competencies and measured by their milestones that are critical to a supervisor’s decision to entrust a learner. 

Slide41:

Skill? Hard skill? Soft skill? A skill  is the learned ability to carry out a task with pre-determined results within a given amount of time, energy and……. Soft skills relates to a person's  "EQ" (Emotional Quotient), the cluster of personality traits, social graces, communication, language, personal habits, friendliness, etc. Not easily quantifiable. Hard skills are any skills relating to a specific task or situation. These skills are easily quantifiable. Hard skills (part of a person's intelligent quotient “IQ” ), are the occupational requirements of a job and many other activities

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Milestones Domain of Competence Competence Entrustable Performance Activity Professional IMG

Benefits of competencies:

Benefits of competencies Organizations align to strategies and job requirements Focuses plans to address missing competencies Focus on skills, knowledge, Attitude & Professionalism Ensures that training and development are aligned Most effective use of training, time and money Provides a competency framework for feedback

Benefits of competencies:

Benefits of competencies Watch over targeted behaviours and outcomes Shared understanding of what will be monitored, measured, and rewarded Facilitates effectiveness goal-setting Development of stepping stones Clear, valid, and achievable benchmarks Takes the guesswork out of career progression Assess candidates’ readiness for the role

International Scenario regarding CBME:

International Scenario regarding CBME

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Canada Royal College (in 1990) USA Accreditation Council for Graduate Medical Education (in 1981) UK General Medical Council (in1858)

Indian scenario CBME curriculum:

Indian scenario CBME curriculum MCI under department of Health and family welfare, in 1933- 1956- GMR (IMG) 2012_8 th October 2016_Novemeber 2018 ( C 2 L 2 P )

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What is the Goal of undergraduate medical training as proposed by MCI To produce ‘Doctors of First contact’ or ‘Primary Care Physicians’ To cater to health needs of the society

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Competency-Based Medical Education (CBME) Scientifically trained professionals for serving the health needs of the society. Fill the gap between education, care delivered, and social health needs. Roles of physician to best serve healthcare requirements of the community From Know to Able to Do

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Competency-Based Medical Education (CBME) Preparing physicians for practice that is fundamentally oriented and organized around competencies (tasks) which are derived from an extensive analysis of Societal and Patient needs It de-emphasizes time based training Promises greater Flexibility, and Learner-centeredness Frank, et. al. 2010

CBME:

CBME CBME –forms basis of Outcome-Based Education (OBE) Learning outcomes assume more importance than learning pathways or processes.

General (GLOBAL) Competencies:

Medical Knowledge Patient care Interpersonal and Communication skills System-based practice Practice-based learning & improvement Professionalism General (GLOBAL) Competencies

Comparison Of Traditional Versus Competency Based Medical Educational Programs:

Comparison Of Traditional Versus Competency Based Medical Educational Programs Variable Structure And Process Based (Traditional) Competency Based Driving Force for Curriculum Content –knowledge Acquisition Outcome-knowledge Application Driving force for process Teacher Learner Path of learning Hierarchical (Teacher to students) Nonhierarchical (Teacher = Students) Responsibility of content Teacher Student and Teacher Assessment tools Single subjective measure (Proxy) Multiple objective measure (Authentic, mimics the real task of profession) Timing of assessment Emphasis on Summative Emphasis on formative Program completion Fixed time Variable time

Traditional Versus Competency – Based :

Traditional Versus Competency – Based

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Steps for planning Competency-Based Curriculum Steps and Strategies for implementation Identification of Competencies Competency identification by consensus opinion of e xperts, Health needs, analysis of physician activities, Public health statistics, Medical Records. Exactly define required competencies and components Content Identification and Program organization Identify corresponding course content. Course organization, sequencing, educational activities. Define desired level of mastery/expertise in each area Define milestones or achievement points Assessment Planning and Program evaluation Identify observable and measurable form of competencies in real setting (EPA). Establish minimum acceptable norms of performance and intervening levels of expertise. Develop a longitudinal assessment program. (Blue print of assessment ) Faculty development and student orientation

Stages of Competence? (UCCU) :

Stages of Competence? (UCCU) Unconscious competence. Has so much practice that it has become "second nature" Can be performed easily Skill can be performed while executing another task Conscious competence. Understands or knows how to do something Demonstrating the skill or knowledge requires concentration Conscious incompetence. Does not understand or know how to do task Does recognize the deficit Values the usefulness of skill Unconscious incompetence. Does not know how to do task Does not recognize the deficit May deny the usefulness of the skill

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Stuart and  Hubert Dreyfus  proposed in 1980 at the University of California, UG ,MBBS (IMG) PG Teacher/ Expert/ Practitioner During Course Entrance

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To perform a role one needs to have multiple specific competencies Overall the reforms focus on Enhancing integration Competency Flexibility and Improvement in quality of undergraduate training

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The revised curriculum of MCI Enlists the Roles and Competencies To achieve the goal of (IMG)

Examples: Competent to Perform CPR to a patient in shock Competent to Obtain informed consent for tubectomy :

Examples : Competent to Perform CPR to a patient in shock Competent to Obtain informed consent for tubectomy

WHAT ARE THE CHANGES?:

WHAT ARE THE CHANGES? The old syllabus was theory oriented New syllabus tends to be outcomes oriented More emphasis on skills and attitude Have competency-based tests Early clinical exposure, right from the first year

Foundation Course:

Foundation Course Aimed at bridging the students from the school environment to a professional environment This will happen in the first few weeks This will help the students gain a level of maturity To help them in acquiring knowledge and experience in many aspects like computers, legal awareness, communication skills, health economics, etc. before they start learning medicine

Early clinical exposure:

Early clinical exposure Present first year MBBS curriculum comprises only the basics Students fail to link them with practical aspects With the new curriculum, the students will have exposure to the practical aspects in the first year itself Myth:- Students from the first year start seeing, taking history, doing examinations, and learning management Truth:- Early clinical exposure to sensitize them for the usefulness of basic teaching to be utilized in clinical scenarios

Integration:

Integration Highly compartmentalized at present Integration an important component of CBME Vertical and horizontal integration Students will be in touch with all subjects throughout the graduation period and they will connect everything happening in many specialties for their improved understanding.

Change in teaching methods :

Change in teaching methods Less focus on didactic lectures (solo subjects) More emphasis on (Student centred) Integrated teaching Group discussion Demonstrations and Tutorials Student seminars Projects Self Directed learning and Peer assisted learning Problem based learning Case based learning Role play

Changes in Assessment:

Changes in Assessment Presently more focus on summative and theory More focus on assessment of performances Formative assessment Multiple time assessment Practical (competencies) OSPE and OSCE DOPS and WPBA Mini-Clinical Evaluation Exercise (Mini-CEX) 360 Degree assessment (including patient surveys) Projects Portfolios

Electives:

Electives Exposure to various aspects of medicine like bio-medical engineering, genetic engineering, psychology, research and health economics. The options are many and each student will get an opportunity during the course where they can choose an area of interest and undergo training This may help them in nurturing their interests and perhaps selecting better career options.

MCI Proposed CBME Based Undergraduate Medical Education:

MCI Proposed CBME Based Undergraduate Medical Education

Three Volumes:

Three Volumes Volume I - Pre and Para clinical subjects Volume II - Medicine and allied subjects Volume III - Surgery and allied subjects

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C2L2P

Total number of outcomes (Competencies):

Total number of outcomes (Competencies) Global Competencies = 5 Subject wise competencies Pre and para clinical subjects = 1148 Medicine and allied subjects = 1299 Surgery and allied subjects = 532 Grand Total = 2979 C2L2P

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Demonstration Observation Assistance Performance

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Curriculum Implementation Support Programme

Advantages of CBME:

Advantages of CBME Focusing on attitude, skill and knowledge all aspects Makes the IMG capable of facing the real world Makes IMG confident Less time and exam oriented Takes the pressure away from learning Learner becomes the driving force in the learning process Learner becomes responsible for achieving competence goals Integration avoids fragmentation of knowledge Ensures that only competent students move on to next phases

Advantages of CBME:

Advantages of CBME Accepts each learner is unique and learns at his/her own pace Teaching “art” of medicine attitude and communication skills Teaching values related to ethics and professionalism Promises greater accountability because assessments are very close to what would actually be done in real life situations Help to regain the trust of the society in medical profession

Challenges :

Challenges Logistical, faculty and Time Faculty training and expertise Many want to maintain the status quo Change requires an excessive amount of work Breaking down competencies into observable milestones may create endless lists and goals, resulting in participant fatigue and frustration. Questionable students acceptability Fear that by targeting milestones, learners may perceive that these tasks are all that are required in their training, rather than striving for excellence

Challenges :

Challenges Inadequate to describe the higher order skills The students, who are used to teacher-driven and time-based learning, may find it difficult to cope with CBME In their pursuit of achieving predefined milestones, there is a risk that learners may stop thriving for excellence The de-emphasis on time-based training may create a chaotic situation wherein learners progress at their own pace A lot of additional resources including workforce and material would be required to implement CBME. The teachers would also face the challenge of altering their attitude and approach to meet the purpose of CBME

Challenges:

Challenges Risk of knowledge ignored due to focus on competencies Need of support systems like eLearning and Skills lab Assessment in CBME is the most daunting challenge Blurs the line between formative and summative assessment Very often improvement in formative will be taken as summative Performance criteria need to be defined Minimum acceptable norms need to be established Workplace Based Assessment most suitable but most difficult Some student may not at all attain all the required competencies

For This New Approach Of Training:

For This New Approach Of Training Success will be tied to CBME being extensively studied Ongoing monitoring and program evaluation Provide important feedback loops Will this new model of CBME will effective? Will it be worth all the change required? Will our patients be better off? Will our society gets the better competent doctors?

Hybrid may be the appropriate solution:

Hybrid may be the appropriate solution To maximize the gains of CBME, a hybrid approach CBME inbuilt in the tenets of the conventional curriculum Gradual replacement of conventional by CBME To ensure that stakeholders would not be overwhelmed by a sudden change To provide an opportunity to measure and analyze the benefits of CBME

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Faculty Development- CBME program and assessment methods differ in many ways from the traditional curricula It is important to orient and train faculty in using the appropriate teaching & assessment methods Of particular importance Direct observation skills Feedback skills

Preparing colleges and faculty :

Preparing colleges and faculty There are Nodal and regional centers Under these the faculty are given a four days training (Basic course) There is also a one-year project-based Advance Course [Fellowship in Medical Education (FIME) ]to create leaders to manage the change in the field Foundation for Advancement of International Medical Education and Research fellowships (FAIMER) Masters in Health Professional Education (MHPE) at KGMU Lucknow

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Basic Course MHPE Basic Course FIME FAIMER

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Medical education is changing Focus on outcomes Need to demonstrate competency as opposed to assuming Assessment, assessment assessment ! Coaching and feedback are essential! Faculty development Develop a change management plan IMG should be C 2 L 2 P CBME is learner centered and focuses on outcomes Competencies – DOC- EPA – Role – Goal

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Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-45. Carraccio C, Englander R, Van Melle E, et al. Advancing Competency-Based Medical Education: A Charter for Clinician-Educators. Acad Med. 2016;91(5):645-9 Carraccio C, Englander R, Gilhooly J, et al. Building a Framework of Entrustable Professional Activities, Supported by Competencies and Milestones, to Bridge the Educational Continuum. Acad Med. 2017;92(3):324-330. ten Cate O, Hart D, Ankel F, et al. Entrustment decision making in clinical training. Acad Med. 2016 Feb;91(2):191-8 Harden RM. Outcome-based education – The future is today. Med Teach. 2007;29:625-9. Medical Council of India Regulations on Graduate Medical Education 2018. Available from: http://www.mciindia.org/ RulesandRegulations / GraduateMedicalEducation Regulations2018.aspx. Accessed November 10, 2018 Medical Council of India. Vision 2015. Medical Council of India. New Delhi. 2011. Available from: http:// www.mciindia.org/ tools/announcement/MCI_booklet.pdf. Accessed November 10, 2018 Singh T, Modi JN. Workplace based assessment: A step to promote competency based training. Indian Pediatr . 2013;50:553-9

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We Need To Try Our Best To Put In Our Maximum Efforts To Train Medical Graduates To Make Them More Knowledgeable, Proficient, Skilled, Competent & Humane Doctors Serving Mankind LET US BEGIN WITH SOME SMALL STEPS TODAY What is our role?

THANKS :

THANKS dixitkumarrakesh@gmail.com Comment or Query?

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