Time spent in medical training and knowledge gained don’t always correlate. That theory has given rise to the concept of competency-based medical education, an outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies.
An education session during the 2023 AMA Annual Meeting offered expert insight from members of the AMA Council on Medical Education on the implementation of competency-based medical education in physician training. Here are some key takeaways from the session.
Calendars don’t dictate competence
Published by the Association of American Medical Colleges, the Core Entrustable Professional Activities for Entering Residency give medical students a baseline for the necessary skills to start graduate medical education. How and when those skills are honed is not linear or calendar-dependent, however.
“People start residency at the same time, but they go toward competency at certain stages,” said AMA member Louito C. Edje, MD, MPHE, associate dean for graduate medical education at the University of Cincinnati Medical Center. “There’s not a straight line to competency. By making time a constant, we end up having a variable, which is achievement. That’s a problem.”
By making time the variable, rather than achievement, a competency-based approach may create variability for the timeframes in which medical students and residents advance to the next steps in their education, said Dr. Edje, who is also a member of the AMA Council on Medical Education.
Can it work?
A competency-based approach is a major departure from the traditional training schedule. It could mean that medical students may potentially advance to graduate medical training before or after the traditional residency start date of July 1.
Dr. Edje spoke of successes in a competency-based medical education approach to residency training at Cincinnati. The institution’s TIMELESS project—an acronym that stands for Transitioning in Internal Medicine Education Leveraging Entrustment Scores Synthesis—involved having two to three internal medicine residents across all training years to advance based on competency. To measure competency, a clinical competency committee met every two months.
Five of nine participating residents were promoted early—with three third-year residents earning promotions to unsupervised practice an average of 4.5 months early and first-year residents earning promotion to indirect supervision an average of 2.5 months early.
“We found that [residents] started asking for a lot of feedback,” Dr. Edje said. “They wanted to know what you thought about their activity and progress.
“There was a lot of motivation when they were appropriately pushed forward earlier that time-base training would normally allow,” she added. “They felt empowered, and they felt safe because of the entrustment relationships we had with them.”
Time-based advancement in UME
Challenges surrounding competency-based advancement are numerous and might be more pronounced at the medical school level where structural barriers such as residency selection can be a hindrance.
The four-year training timeline does offer opportunities for growth in other areas once medical students have demonstrated competencies in their core skills.
“If everybody needs to finish at the same time, let’s not worry about that,” Kelly J. Caverzagie, MD, associate dean for educational strategy at the University of Nebraska College of Medicine and also a member of the AMA Council on Medical Education. “If every one of you as a medical student has learned everything you could possibly learn and there’s nothing left to teach you, that’s a wonderful problem to have.”
“A lot of medical schools are approaching it knowing you can’t move the Match forward for your own students but knowing that is our system, and as it is there are ways to work within it to continue learning and growth.”
Dr. Edje pointed to the University of Michigan School of Medicine as an institution that will allow students to pursue an additional degree, such as an MPH, if they are displaying competency ahead of their time-dependent advancement from medical school.
