The Josiah Macy Jr. Foundation, which is committed to advancing health professions education to optimize health and health care, convened a group of educators and leaders from medicine, nursing, and pharmacy in a three-day conference in June 2017. The goal of the conference was to explore the value of and challenges to adopting competency-based, time-variable education as the dominant framework for health professions education in the 21st century. Working from the existing literature as well as from five commissioned papers, the assembled experts debated the topic and arrived at a consensus—competency-based education holds tremendous promise to positively impact both our educational and health care systems. A monograph summarizing the conference recommendations and the commissioned papers is available on the Josiah Macy Jr. Foundation website. From this conference, the idea of a supplement to Academic Medicine on the opportunities and challenges of competency-based, time-variable education was born.
Medical education institutions are entrusted with preparing a physician workforce that is capable of and committed to providing reliably safe, timely, effective, efficient, equitable, and patient-centered care. Educators around the world have accepted the need for health professionals to master competencies in domains that extend well beyond those that can be tested with a high-stakes multiple-choice exam.1–3 Physicians must not only master a body of knowledge but also possess the ability to apply that knowledge in service to others, conduct themselves as professionals, work effectively in teams, communicate compassionately with patients and respectfully with colleagues, collaborate to improve systems of care, and engage in critical reflection and lifelong learning.4 The amount of time it takes to master all that is needed to begin to serve others as a physician has never been adequately established.
This recognition of the need to teach and assess the broad set of competencies that physicians must master to serve 21st-century patients has provided the foundation for competency-based, time-variable education. Educators and regulators enthusiastically support the concept. Accrediting bodies, such as the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education in the United States, require that educational programs identify competencies that graduates must meet prior to transitioning between programs and into practice. New curricula and innovative learning activities have been implemented at both the undergraduate and graduate medical education levels to help graduates meet these competencies.5–8 New assessment strategies and tools, such as milestones and entrustable professional activities, have been adopted to improve the reliability of judgments about learners in educational programs.9–11
Unfortunately, although the building blocks of competency-based, time-variable education exist in most medical education programs, few institutions have fully embraced the philosophy of competency-based education.12,13 Even fewer have engaged in the organizational redesign required to fully realize the potential of this framework.6,11,14 Defining the objectives for education is one thing, but creating programs that ensure that every individual student and resident meet these objectives is a step that has not been taken. The time has come for a major redesign of health professions education, one that prepares health care professionals to learn continuously in workplace communities of practice; to participate actively in the ongoing assessment of individual and collective effectiveness; and to engage enthusiastically in the education of the next generation of health care professionals to serve our patients and communities.
In this supplement, we and the authors of the other articles investigate the potential of competency-based, time-variable education, deployed across the continuum of medical education, to provide us with the physicians we want in the systems we need. Although the primary focus of most of these articles is medical education, we believe that the principles, opportunities, and challenges of competency-based, time-variable education can and should be applicable to all health professions.
Challenges With Today’s Approach to Medical Education
In today’s medical education environment, time is our nemesis. Educational structures are time bound. Learners dwell in discrete phases of education for a predetermined amount of time (in the United States, that is no less than 130 weeks of medical school or 3 years of an internal medicine residency), and they transition to the next phase of training after passing time-bound courses (6 weeks in pediatrics, 8 weeks in surgery) and demonstrating satisfactory performance on exams that focus primarily on their mastery of factual knowledge (e.g., licensing exams, certifying exams). All learners commence education labeled with their year of graduation (“Class of 2022”) and must be prepared to enter the National Resident Matching Program as a cohort or risk the stigma and the economic consequences of delayed entry into a residency or fellowship.
Learners and faculty are time challenged. Faculty supervisory assignments on clerkships or residency rotations are brief and insufficient to develop the trusting relationships needed for effective, critical assessment.15 Within those short rotations, faculty have little time to engage in the direct observation that competency-based education demands.16 Faculty find themselves asked to make assessment judgments (e.g., meets, exceeds, does not meet competency) with limited information. They lack both skills and time to engage in coaching dialogues with their learners and instead communicate these assessment judgments through electronic forms.17,18 Students, realizing the short time they have to impress a faculty member and earn the grades they need to pursue their desired residency, view assessment as a threat to be avoided rather than as an opportunity to be embraced.18–21 They use time to study to earn higher scores on episodic high-stakes examinations rather than to optimize patient care competencies in the workplace. Learners identified as needing or desiring additional time to meet competencies are viewed as failures. Consequently, these students spend time arguing about the veracity of the assessment rather than strengthening the part of their performance that is weak. Learners who are capable of accelerating their progress through formal education are unable to do so in the current system and thus must add time to the total length of their education if they wish to engage in enrichment activities such as research, service, or family building.
Many question the quality of learning and the reliability of assessments made under these time constraints and challenges. Program directors raise concerns that the graduating medical students or residents they receive into their programs are not prepared for the roles they need to assume as interns or fellows.22–26 Nonphysician health care providers readily identify students, residents, and practicing physicians who have not mastered competencies in teamwork, communication skills, and professionalism.27 Employers decry the need to retrain newly employed physicians in systems-based practice.28 Certified physicians struggle to accept the need for oversight of their practice-based learning. Persistent problems with health care safety, quality, and equity are at least partly attributable to individual physician competence.
Competency-Based, Time-Variable Education as an Opportunity for Transformation
Competency-based, time-variable education is a comprehensive approach to curriculum, instructional methods, learning strategies, assessment programs, and program evaluation that is based on a framework of observable and assessable abilities.29 It is focused on meeting the needs of patients by providing the highest-quality health care. Competency-based education begins with an uncompromising focus on translating the needs of contemporary society for improved health care into competencies that must be mastered by health professionals across all disciplines, from medicine to nursing, pharmacy, dentistry, and beyond.4
Competency-based, time-variable education views health professions education as a continuous process, beginning when a student enters a health professions school and ending when that individual retires from the profession. Time variability refers to the institutional acceptance of the need to adapt the pace, intensity, or duration of training to ensure that the progress of an individual through and across the phases of education occurs as soon as and only when she or he has mastered essential competencies. Advancement through the stages of formal education and into practice is based not on the passing of time but on the demonstration of trustworthiness. Educational opportunities and support systems are designed to enable learners to acquire the skills and knowledge they need to demonstrate that they can be trusted to care for a diverse set of patients in a wide variety of contexts with decreasing intensity of supervision. Although time constraints are not totally absent, they are secondary.
Competency-based, time-variable education is facilitated by robust programs of assessment that holistically measure all domains of competence. In a competency-based, time-variable system, assessment is not a grade that one receives from an expert at the end of a rotation or after fearfully taking a periodic, knowledge-focused, high-stakes exam. Instead, it is a process of ongoing, multimodal measurement and coaching that one enthusiastically engages in to guide personal learning and improvement (i.e., assessment for learning). Although institutions and the public like to believe that training programs deliver clinicians who have attained the highest possible level of mastery, we all know that the development of expertise is a lifelong process. High-stakes decisions about transitions between and out of training are made once sufficient evidence supports the assertion that this individual can be trusted to provide safe care for a variety of patients in a diversity of contexts. This evidence is aggregated from diverse viewpoints (faculty, patients, peers, other professional colleagues) of the individual’s abilities in multiple competency domains across different contexts to provide the most reliable assessment of future success.30
In competency-based, time-variable education, time is a resource for the learner, rather than a threat. Learners who are able to master a set of competencies before the end of a given stage of education can use the remaining time to pursue work on a more advanced level or toward an added competency, engage in co-curricular work such as research or service activities, or engage in life experiences such as family building. The virtue lies not in training in the shortest possible time but at the highest professional level and breadth. At the same time, competency-based education does not allow excellence in one competency domain (e.g., medical knowledge) to compensate for marginal performance in another (e.g., interpersonal communication). Learners needing additional time to master a set of competencies are not passed along as “good enough” or branded as “failures” in need of remediation; they are provided with additional opportunities to master the skills they need to be effective professionals, deserving of the public’s trust for quality care. Detours in individual curricula may be justified for very different reasons.
Competency-based assessment is supported by new roles and skills for faculty and learners. Faculty focus on observing and describing learners’ current abilities in relation to the desired future state and providing concrete suggestions for learners to progress, rather than on deciding what grade the learners receive.17 Learners know the competency goals they must achieve to transition to the next phase of their career and actively seek out both learning experiences and critical feedback to help them achieve those goals.20 Committees of specially trained faculty and staff analyze learners’ performance and are responsible for assembling and analyzing formative assessment data to identify when learners are ready to transition to the next level of education.31 Technology supports this process and these relationships. Learners have ready access to digital learning tools so that they can access lessons as soon as they are ready. Administrative technology collects multiple instances of feedback and assessment to provide the data needed to make summative decisions.6,30 Performance and achievement data follow the learner as she or he moves through formal educational programs and into practice, facilitating continuous learning and competency enhancement across the continuum of medical education and into practice.
The Theoretic Basis for and Emerging Examples of Competency-Based, Time-Variable Training
In this supplement, ten Cate and colleagues32 summarize the pedagogical and neuroscience theories that support competency-based assessment and time variability. The authors make the distinction between achievement variability or the time an individual requires to master a given set of competencies, and the duration of training variability or the time an individual requires to become ready to take on the responsibilities inherent in the next stage of professional development. Importantly, they note that the duration of training cannot simply be described as the sum of the time required to master and demonstrate different competencies; additional time is needed for individuals immersed in a health professions program to consolidate their learning and mature as professionals. Teunissen and colleagues33 add to the theoretic foundation of this work by emphasizing the importance of learning in different practice contexts as an essential component of identifying readiness to transition between different stages of education and practice.
There are a number of examples of competency-based, time-variable program designs from medical and other health professions programs. For example, Hoff and colleagues34 describe individualized, competency-based, time-variable residency programs in the Netherlands that allow residents to pursue training part-time, affording them time for family building, additional clinical work, and research experiences. In true competency-based fashion, demonstrated expertise gained in one stage of training may be used to shorten training in a subsequent stage. In an example from nursing education, Litwack and Brower35 describe the flexible competency-based bachelor of science in nursing degree program at the University of Wisconsin–Milwaukee. In the United States, the Education in Pediatrics Across the Continuum program has allowed a small number of students at four pilot institutions to opt into pediatrics at an early stage of their undergraduate medical education and then transition into that institution’s pediatric residency program when they are ready, rather than waiting for the usual National Resident Matching Program process.36 In addition, multiple medical schools in the United States are engaged in pilots of an undergraduate medical education to graduate medical education continuum for selected students.37
Strategies and Challenges to Implementing Competency-Based, Time-Variable Education
Although all signals suggest that health professions education programs, their faculty and learners, and administrative partners and regulators generally agree in principle with the importance of competency-based education, full acceptance of such programs is not universal.38,39 Even those who are supporters find that implementation can be challenging, as described by many of the authors in this supplement. Many health professions education programs have adopted elements of competency-based assessment (such as milestones and entrustable professional activities), but the robust programs of assessment described by Gruppen and colleagues40 as essential to the competency-based, time-variable training approach are rare. Englander and Carraccio41 describe the imperative of reversing our current system of discontinuity in medical education and supporting new roles and relationships between faculty and learners if we wish to implement the types of assessment and coaching strategies on which competency-based education is based. Kogan and colleagues42 and others43,44 detail the many existing, time-bound structures (e.g., program standards from the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education, National Resident Matching Program procedures, licensing requirements, board certification standards) that interfere with competency-based transitions within, between, and beyond the phases of formal education. Substantial change management, project management, collaborative work, and economic investment have been invested to shift from traditional to competency-based, time-variable education in undergraduate medical education, as Mejicano and Bumsted45 describe at Oregon Health and Science University School of Medicine. Finally, Custers and ten Cate46 remind us that current time-bound practices are based in the historical evolution of the concepts of time and proficiency and have no true empiric basis.
Although a shift in focus from time-defined, discrete phases of education to competency-based, time-variable education across the continuum of learning and practice will not be easy, it is essential to training the health care professionals we want in the systems we need. Around the world, health care delivery systems are being transformed to better meet the needs of patients and communities by providing care that is reliably high quality, reassuringly safe, measurably equitable, and economically sustainable. Systems thinking, with a relentless focus on measuring outcomes and continuously improving processes to achieve those desirable outcomes, is front and center in the national and international discourse on optimizing care at all levels of the health care system. To be effective in this environment, health care professionals must be trained to similarly engage in the measurement of their abilities and performance and to identify the types of educational experiences that drive them toward expertise. To fulfill our commitment to preparing this new type of health care professional, educational systems, the institutions where the health care of the future begins, must transform themselves into models of competency-based, time-variable learning.
We are at a crossroads. Competency-based education has become a significant movement, and there is no way back. For the sake of patient safety, a standardized duration of training, in unconnected compartments of the health professions education continuum, is likely not the landscape of the future. Rather, individualized educational pathways, as advocated by Cooke and colleagues,47,48 could transform the landscape into a marshalling yard, in which individuals develop a dynamic personal portfolio of certified qualifications that are flexible and tailored to both their individual needs and the needs of the health care environment. Doing so will ensure competency-based, safe, high-quality medical practice throughout a health care professional’s life.
This supplement would not have been possible without the invaluable support of the individuals who reviewed the included manuscripts. The authors would like to thank the following reviewers: Eva Aagaard, MD, Lisa Bellini, MD, Carol Carraccio, MD, Kelly Caverzagie, MD, Ming-Ka Chan, MD, Kathy Chappell, RN, Carrie Chen, MD, PhD, Kinga Eliasz, PhD, Robert Englander, MD, MPH, Tonya Fancher, MD, MPH, Eric Holmboe, MD, Adina Kalet, PhD, Kim Lomes, MD, Daniel Schumacher, MD, Claire Touchie, MD, MMEd, and Diane Wayne, MD.
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