The speed at which medical students grow into capable physicians is going to vary, and curriculum should not be a barrier that prevents learners from progressing. That’s the logic behind a nascent program at Oregon Health & Science University (OHSU).
Now, “medical education programs are very much time-fixed,” said Tracy Bumsted, MD, associate dean for undergraduate medical education at OHSU. “Having a competency-based time-variable training program turns that all on its head and basically implies that the outcome is fixed but the time is variable.”
Still in the development stages, OHSU’s Program to Accelerate Competency-Based Education (PACE) is looking to de-emphasize the curricular calendar. Instead of adhering to a set graduation date, PACE would allow selected students to progress through the medical school curriculum at their own speed. Graduation would take place when a med student demonstrates expertise in a number of arenas. Once that happens, they would enter an OHSU residency program.
Creating competent residents
In 2014, OHSU—one of 32 member schools of the AMA Accelerating Change in Medical Education Consortium— implemented a curriculum overhaul. Branded as YourMD, the new curriculum was designed to prepare medical students for residency training and practice in the modern health care environment.
The curriculum called for new measures of competency-based assessment. Those measures include a list of 40-plus distinct competencies, which fall within broad topics such as medical knowledge and professionalism, and the 13 Core Entrustable Professional Activities for Entering Residency (EPAs)—students earn digital badges once they have demonstrated ability in an activity, including tasks like entering orders and obtaining consent.
OHSU’s shift to a largely competency-based curriculum is progressing. The competency measures will become graduation requirements in the coming years. Implementing a time-variable element would be a second phase that is proving to be both ambitious and challenging.
Dr. Bumsted and her colleagues don’t have to look far to find an example of the possible benefits of a time-variable model in action. OHSU’s Oral and Maxillofacial Surgery program has instituted an accelerated path for students who have graduated from dental school and enter medical school as aspiring oral surgeons.
Rather than have those students repeat much of the basic science curriculum they likely covered during dental school, OHSU allows them to pass the scientific learning phase in a matter of months.
To do that, students must register a passing score on the USMLE Step 1 exam and then take a high-stakes, 10-station Objective Structured Clinical Exam (OSCE). If they pass, they can move on to clinical training, which is also accelerated.
Getting out of learners’ way
A number of OHSU faculty, staff and leaners are offering input on a plan to implement a time-variable curriculum on a larger scale. As presently constituted, PACE would allow students who are demonstrating excellence during the first year and a half of medical school to apply for their second year and be granted access by spring.
At that point, students would follow an individualized curriculum with an area of focus of their choosing. They would be accepted into an OHSU residency program mid-way through their third year of medical school.
“The residency program would have accepted them and know the student well,” Dr. Bumsted said. “The student would have [faculty] mentoring and an individualized curriculum while in med school to get them ready for their residency program.”
A student can move on to the residency program when they demonstrate the desired ability in OHSU’s milestones and EPAs. They would likely be doing so outside of the traditional GME calendar.
If a medical students is “ready to be a resident, we should get out of their way and let them be a resident. Ideally, they are going to be able to get out of GME sooner as well,” Dr. Bumsted said. “Then they can get out and practice and serve society faster than they would if you made them to the one-size-fits-all, time-fixed model.”
There is no set date for PACE’s implementation. It will require OHSU to confront a number of challenges—getting an exemption from the National Resident Matching Program and figuring out the financial issues with a time-variable curriculum are among them. Those challenges, however, also present opportunities.