Emancipating educationAbraham Lincoln Presidential Library
Springfield, IL
September 28, 2013Felix Ankel, MD
Watson
Human
Curate
From Hierarchies to Networks
Community of Practice
Community of practice
Create
All,We recently had a case where an intern, when asked by the nurse taking care of a patient with a NSTEMI, said it was okay for the patient to go to the bathroom off monitor. You guessed it; the patient subsequently was found in arrest in the bathroom. In our reactionary culture, some of our faculty are advocating for all decisions to go through the 3rd year resident and to make sure the intern doesn’t make decisions that adversly affect patient care. So, the questions for the collective:
• Do you have a formal statement about what interns are allowed to do?
• If not formally, do you have a process of what interns are allowed to do?
• Are the nurses the “determiners” of who to go to?
The “Miracle” of Medical Education
Slide credit Eric Holmboe
•Autonomy•Complexity•Context
Autonomy
Able to take full responsibility for going beyond existing
standards and creating own interpretations
From the professional standards for conservation, Institute of Conservation (London) 2003, Based on the Dreyfus model on skill acquisition
Complexity
Holistic grasp of complex situations, moves between
intuitive and analytical approaches with ease
From the professional standards for conservation, Institute of Conservation (London) 2003, Based on the Dreyfus model on skill acquisition
Context
Sees overall “picture” and alternative approaches; vision
of what may be possible
From the professional standards for conservation, Institute of Conservation (London) 2003, Based on the Dreyfus model on skill acquisition
The Light at the End of the Tunnel…
1. Explosion of medical knowledge: need to re-conceptualize competence
2. The growth of performance measurement: quality and safety indicators, patient experience, etc.
3. Shift to interprofessional care and changing scope of practice
4. Advances in cognitive science: expertise, retrieval practice, situated and distributed cognition, etc.
5. Critical role of “context” – complex adaptive systems
6. Growing public pressure to change7. HIT/Clinical Decision Support
…Is a Freight Train
Slide credit Eric Holmboe
Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010
Why CBME: 21st Century Healthcare
Next Accreditation System
22
Continuous Oversight &
Improvement Emphasis
Milestone Reporting
(semi-annually)
Case LogsResident &
Faculty OpinionsProgram &
Institutional Information
Uniformity of Milestone Reporting• 5 levels of proficiency
– Novice, Beginner, Competent, Proficient, Expert• Level 4 - The ABEM certification standard
– By definition where an individual should be at time of graduation
• Level 5 - Attained after practice• Narrative anchors• Based on knowledge, skills and abilities (KSAs)• Balance between
– Deconstruction (microtasks)– Integration (complex performance)
Reliabilities across methodsslide created by Cees van der Vleuten 2012
TestingTime inHours
1
2
4
8
MCQ1
0.62
0.76
0.93
0.93
Case-BasedShort
Essay2
0.68
0.73
0.84
0.82
PMP1
0.36
0.53
0.69
0.82
OralExam3
0.50
0.69
0.82
0.90
LongCase4
0.60
0.75
0.86
0.90
OSCE5
0.47
0.64
0.78
0.88
1Norcini et al., 19852Stalenhoef-Halling et al., 19903Swanson, 1987
4Wass et al., 20015Petrusa, 2002
Carraccio C, Wolfshtal SD, Englander R, Ferentz K, Martin C. 2002. Shifting paradigms: from Flexner to competencies. Acad Med 77(5):361-367. p 362.
Structure- and process-based
Competency-Based
Driving Force: Curriculum Content Outcome
Driving Force: Process Teacher Learner
Path of learning Hierarchical Non-hierarchical
Responsibility for content Teacher Student and teacher
Goal for educational encounter Knowledge acquisition Knowledge
application
Program completion Fixed time Variable time
What are the characteristics of a highly functioning CBME system?
“This has resulted in the world’s first pilot of a competency (as opposed to time) based orthopedic training program”
Macrotrends• From hierarchies to networks (CoP)• From individual experts to wisdom of crowds (CCC)• From knowledge to competency (CBME)• From carrots and sticks to autonomy, mastery, and
purpose (Dreyfus and Dreyfus)• From function to design (CLER visit)• From argument to story (narrative anchor)
Drivers and themes for innovation
• Curation and Aggregation
• Communities of Practice
• Creation of Tools
• Assessment• Time• Money
Competency by design
Thank you
• Brad Gordon• Rob Cooney• Jessie Nelson• Derek Schmidt• Jason Frank• Ali Jalali• Cees Van der Vleuten
• Tom Nasca• Mary Healy• David Griffen• Julie Kirkham• Eric Holmboe