CompetencyCompetency--Based vs.Based vs.CompetencyCompetency Based vs. Based vs. FaithFaith--Based Education: Based Education: A W S i b tA W S i b tAre We Serious about Are We Serious about

Practicing What We Preach?Practicing What We Preach?Practicing What We Preach?Practicing What We Preach?

Larry D. Gruppen, Ph.D.U i it f Mi hi M di lUniversity of Michigan Medical

School

Competencies CompetenciesCompetencies CompetenciesCompetencies, CompetenciesCompetencies, Competencies

• Competencies not a new concept• Competencies not a new concept (even in med ed)– Mid-’90s in UGME– Turn of millennium: ACGME, Scottish ,

Doctor, CANMEDS– Present: numerous schools postgradPresent: numerous schools, postgrad

programs, speciality organizations

Many FrameworksMany FrameworksMany FrameworksMany Frameworks

• Scottish Doctor: 12 categories in 3 broad• Scottish Doctor: 12 categories in 3 broad domainsCANM d 7 l• CANMeds: 7 roles

• ACGME: 6 domains• IIME: 7 categories

• All share many similarities with some special emphasesspecial emphases

Competencies and EducationCompetencies and EducationCompetencies and EducationCompetencies and Education

• Programs and schools mapping• Programs and schools mapping curricular goals onto competencies– Often use nationally-defined

competencies– Many develop their own

• Impact of this focus varies• Impact of this focus varies– For many, rearranging deck chairs– For others, impetus for real reform

Broadly Based MovementBroadly Based MovementBroadly Based MovementBroadly Based Movement

• Not just medical education• Not just medical education• Other health sciences• K-12 education (teacher and learner

competencies)competencies)• Other professions (clinical counseling,

engineering, public health)

But Aren’t We Already But Aren’t We Already CC ??CompetencyCompetency--Based?Based?

• TIME based education• TIME-based education– Students need a defined amount of time

on task or topic to become competent– e.g., 6 weeks in pediatrics, 140 hrs with g p

anatomy, 90 minutes on ethics– [But we really have no clue how much[But we really have no clue how much

time it takes]

But Aren’t We Already But Aren’t We Already CC ??CompetencyCompetency--Based?Based?

• TIME based education• TIME-based education• FAITH-based education

– Take on faith that within a set time, students will learn what they need to ylearn and (miraculously) be competent

– [But we really have little evidence for that[But we really have little evidence for that belief]

Background for What FollowsBackground for What FollowsBackground for What FollowsBackground for What Follows

• Group commissioned by Dean to• Group commissioned by Dean to rebuild med ed from scratch

• Not just curriculum, but everything from admissions onwardfrom admissions onward

• 10 educators, ½ day/week, three yearsyears

• Lots of blind alleys (lots of fun)y ( )

ENCOREENCOREENCOREENCORE

• “Ensure competence inspire• Ensure competence, inspire excellence”

• Competency- or outcome-based frameworkframework

• 120 presenting complaints to organize contentcontent

Nine CompetenciesNine CompetenciesNine CompetenciesNine Competencies

• CommunicationCommunication• Clinical skills• Self-assessment and learning managementSelf assessment and learning management• Professionalism• Scientific reasoningg• Social context of health and disease• Systems of care deliveryy y• Diagnosis and risk assessment• Therapeutics and management

Outcomes as DriverOutcomes as DriverOutcomes as DriverOutcomes as Driver

Learning Activities

Learning Objectives

Outcomes AssessmentAssessment Competency Criteria

120 patient symptomsy p

Breast Mass

Headache

Jaundice

Joint Pain

Chest Pain

Trauma

etc

Implications of CompetencyImplications of Competency--Based Education (CBE)Based Education (CBE)

What Drives the SystemWhat Drives the SystemWhat Drives the SystemWhat Drives the System

• Competency outcomes drive• Competency outcomes drive curriculum objectives

• Curriculum does NOT drive outcomes

When Curriculum Drives When Curriculum Drives CompetenciesCompetenciesCompetenciesCompetencies

TeacherLearnerCompetencies Curriculum (learning

activities)

Outcomes Objectives

Teacher / CurriculumStudent / Learner Teacher / CurriculumEvaluation

Student / LearnerAssessment

Standards?

When Competencies Drive When Competencies Drive CurriculumCurriculumCurriculumCurriculum

TeacherLearnerCompetencies Curriculum (learning

activities)

Outcomes Objectives

Teacher / CurriculumStudent / Learner Teacher / CurriculumEvaluation

Student / LearnerAssessment

Standards

What Drives the SystemWhat Drives the SystemWhat Drives the SystemWhat Drives the System

• Competency outcomes drive• Competency outcomes drive curriculum objectives

• Curriculum does NOT drive outcomes

• Fundamental shift from teacher-centered to learner-centered orientation

Curriculum OrganizationCurriculum OrganizationCurriculum OrganizationCurriculum Organization

• One size does NOT fit all learners• One size does NOT fit all learners– Start in different places– Proceed at different rates– Have different goalsHave different goals– Attain competence at different timesR i fl ibilit i l i• Requires flexibility in learning activities, timing, and duration

AssessmentAssessmentAssessmentAssessment

• Assessing competence becomes• Assessing competence becomes central

• Assess many things we aren’t doing now - need new methodsnow need new methods

• Sampling of competencies and contextscontexts

• Address risk of counting only what is g ymeasurable

Setting StandardsSetting StandardsSetting StandardsSetting Standards

• Reveals the hidden differences in• Reveals the hidden differences in faculty beliefs about ‘competence’– Is ‘competent’ really good enough? Don’t

we want ‘excellent?’• Specific to outcome, assessment

method and stage of learningmethod, and stage of learning• Formative vs. summative standards• A lot of work

Assessment and LearningAssessment and LearningAssessment and LearningAssessment and Learning

• Separate teaching from assessing• Separate teaching from assessing– Conflict of interest for faculty in

conflating teaching and evaluation– Learners fear exposing ignorancep g g

• Clearer separation of formative and summative feedbacksummative feedback

• Shift in balance between summative and formative assessment

Curriculum ManagementCurriculum ManagementCurriculum ManagementCurriculum Management

• Learning management system• Learning management system– Thousands of competencies, outcomes,

objectives– Individualized progress through systemp g g y– Sequencing of educational activities– Flood of assessment data– Flood of assessment data – Explosive combinatorics

LearnersLearnersLearnersLearners

• Changing learner responsibilities• Changing learner responsibilities– Self-direction– Self-assessment– Comfort with ambiguity and choiceComfort with ambiguity and choice

• Learning communityA h l l– Asynchrony among learners ⇒ no longer ‘class’ based

FacultyFacultyFacultyFaculty

• Changing faculty responsibilities• Changing faculty responsibilities– NOT teach whatever you want,

whenever you can– Create experiencesp– Set expectations – Mentoring and advising– Mentoring and advising– Perform “real” assessment (designated,

trained assessors)trained assessors)

In SummaryIn SummaryIn Summary…In Summary…

• CBE could be a revolutionary change• CBE could be a revolutionary change from time(faith)-based education

• But revolutions are painful and messy – Fundamental shift in ‘power’Fundamental shift in power– Assessments (and standards) are key

M i CBE i h ll i t– Managing CBE is a challenging prospect– Daunting logistics

Are We Ready for a Revolution?Are We Ready for a Revolution?Are We Ready for a Revolution?Are We Ready for a Revolution?

• Flexnerian revolution of 1910• Flexnerian revolution of 1910– Full implementation took c. 40 years– 200+ proprietary schools closed– Bitter, acrimonious, and protractedBitter, acrimonious, and protracted

battles• Can we afford the status quo?• Can we afford the status quo?

Thank youThank youThank youThank you

ENCORE Next StepENCORE Next StepENCORE Next StepENCORE Next Step

• 6 week pilot 12 student volunteers• 6-week pilot, 12 student volunteers• 3 complaints: trauma, hypoglycemia,

renal failure• Develop learning experiences• Develop learning experiences,

assessments• Examine student experience and

acceptancep• Explore logistics