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Envisioning a True Continuum of Competency-Based Medical Education, Training, and Practice

Cate, Olle ten PhD; Carraccio, Carol MD, MA

doi: 10.1097/ACM.0000000000002687
Perspectives
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The existing structure of physician education has developed in siloed stages, with consecutive degrees and certifications and progressively longer training programs. As further fragmentation of health care and training systems will not improve the quality of care and education, the authors argue that a new vision of education, training, and practice as a continuum is needed.

They advocate for a model of competency-based medical education that merges with competency-based medical practice. In this system, education and training will result in individual, dynamic portfolios of valid entrustable professional activities (EPAs) for which physicians are certified. Physicians can maintain and renew that entrustment as long as the EPAs remain within their scope of practice. Entrustment occurs initially during training but is then granted for new activities as physicians’ careers evolve.

This model accounts for the need to keep pace with changes in population health needs and expectations of competence over time. It de-emphasizes the divides between the stages of training and views the continuum from undergraduate medical education until retirement as a whole. Key obligations of self-regulating medical professionals include both the reception and the provision of supervision from and for others, respectively. Learning must be embedded in practice to address expectations regarding new knowledge and skills as they evolve with scientific and technological advances.

Entrusting physicians to deliver effective and safe care, based on their performance of the requisite EPAs without supervision, should ensure that they provide high-value, quality care to patients.

O. ten Cate is professor of medical education and senior scientist, Center for Research and Development of Education, University Medical Center Utrecht, Utrecht, the Netherlands; ORCID: https://orcid.org/0000-0002-6379-8780.

C. Carraccio is vice president of competency-based assessment, American Board of Pediatrics, Chapel Hill, North Carolina; ORCID: https://orcid.org/0000-0001-5473-8914.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The opinions presented in this article are those of the authors and not of the American Board of Pediatrics.

Correspondence should be addressed to Olle (Th.J.) ten Cate, Center for Research and Development of Education, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, the Netherlands; telephone: (31) 88-75-57010; email: t.j.tencate@umcutrecht.nl.

The stages of medical education, training, and practice have developed piecemeal over the last few hundred years. This opportunistic development has led to siloed curricula, which have arisen arbitrarily rather than from the competencies that physicians must attain to meet population health needs.1 Once out of training, some members of the profession assume that physicians remain up-to-date throughout their careers and limit their practice to self-defined areas of professional competence. A century ago, this model may have been justified. The medical degree covered much of the knowledge and skills physicians needed to enable practice for a lifetime, and only a minority of graduates advanced to specialized training. This is not the case today. To date, however, a medical license in many jurisdictions still permits a scope of practice beyond a given physician’s capabilities.

As biomedical knowledge has increased and health care systems have become more sophisticated, the dominant reaction in education has been to extend training for longer periods of time,2 with each extension representing a more subspecialized domain. We believe that medical education has now arrived at a point where this approach is no longer functional; further lengthening of training is simply unsustainable.3 Training programs will become too long; the age at which physicians begin unsupervised clinical practice too high4; the requirements to complete training, become certified, and continue certification too complex5; and the costs too prohibitive. An evolution to a more effective and efficient approach to education and training is needed. The purpose of this article is to propose a competency-based framework of entrustable professional activities (EPAs) that will connect the education, training, and practice continuum.

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Reconsidering the Learning–Practice Divide

We argue that the dominant pedagogical model of learning and then practice is outdated. It suggests that a diploma guarantees sufficient knowledge and skills and marks the transition from no practice to full practice. To deliver high-value care, medical trainees must learn to acquire, practice, and maintain the requisite competencies from entry to medical school through the continuum of education, training, and practice to retirement. Educators must therefore develop a continuum view of medicine, in which education, training, and practice are not separate, sequential stages but, rather, ongoing parallel processes that supplement each other simultaneously and build over time. Practice should be an essential component in all career stages, from undergraduate medical education (UME) through continuing professional development.

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The Value of Ongoing Credentialing

The attainment of expertise requires many years of experience and deliberate practice.6 The development of expertise in students, residents, fellows, and practitioners begins on the first day of medical school and continues for the entirety of a physician’s career. Some develop expertise slowly and others rapidly, depending on their individual capabilities, attitudes, and agency, and on the curricula offered and the opportunities in their learning and workplace environments.7 A general medical license and a specialty certification recognize the physician’s ability to successfully demonstrate the requisite general knowledge and skills at that moment in time. They do not necessarily evolve along with the physician’s career to mirror the specific competencies that individuals build within their defined scope of practice. The traditional licensing process, which is based on a broad scope of practice and limited specificity, is no longer aligned with the ever-increasing specialization of physicians’ practices. In addition, continuing certification may not always reflect the evolution in an individual’s practice over time. A more flexible and ongoing process within the existing system that can provide the necessary reassurances about physicians’ current knowledge and skills would better serve the needs of patients and credentialing organizations.8

The critical questions for educators, institutions, employers, and the public, then, are how to know whether learners are ready to be trusted to apply their cognitive, technical, and other skills to care for patients without supervision and whether physicians have maintained their knowledge and skills over time. Broad diplomas and certificates can be necessary thresholds for assuming increased responsibilities, but they are insufficient to attest to physicians’ longer-term competence or their acquisition of new competencies over time. Ongoing deliberate practice must continue throughout physicians’ careers for them to develop, achieve, and maintain competence and advance toward expertise. Only then can a continuous state of competency-based practice be achieved.

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Competence Development Targeted at Scope of Practice

Competency-based medical education (CBME) has emerged as an approach to clinical training in many countries. In the CBME framework, the required abilities and outcomes of training are defined according to the needs of the patient populations served.9 With the introduction of CBME, the potential to align education, training, and practice has become real but has not been realized to its full potential. EPAs can provide a developmental model to unite these stages into an integrated continuum.10,11 EPAs are units of professional practice that can be fully entrusted to a learner or physician once he or she has demonstrated the necessary competence to execute the activity unsupervised.12,13 EPAs serve as a mechanism to articulate the competence expectations for individual physicians within a defined scope of practice.

The introduction of EPAs into CBME has presented the medical community with the potential to create a true continuum of education, training, and practice.10,11 Using EPAs as the bridge, educators can create a link across career stages. Using specialty-specific EPAs derived from the needs of the population being served, educators can create a curriculum for graduate medical education (GME) training that will enable learners to achieve the desired outcomes for entering practice. Taking a step back and using the Core Entrustable Professional Activities for Entering Residency (Core EPAs),14 educators can create a curriculum for UME that will enable learners to enter GME with the requisite competencies; the earlier in training a physician is, the less specific the EPAs will be. In essence, EPAs act as building blocks. For example, the foundations of many houses are similar—they all may be brick or stone. Once the foundations are laid, the houses will be built with a limited number of materials, but they ultimately will become different sizes and styles, like the EPAs in GME and practice for individual physicians.

In aggregate, EPAs reflect the practice outcomes of an educational program. These outcomes are usually not achieved until the very end of the training program. Rather, with an EPA model, learners can safely start contributing to patient care from an early stage.15 They gradually grow into a community of medical practice as supervision lessens, and they become increasingly permitted to complete professional activities that are ultimately entrusted to them without supervision.16–18

Individualized, time-variable training is a direct consequence of CBME. If training outcomes are the fixed standard, the time needed to attain each outcome will vary among learners. Allowing for such variability is not easy and not yet common,19 but it is necessary to facilitate the achievement of desired outcomes when learners need more or less time to achieve those outcomes. Examples from other countries show how such flexibility can be created to a certain extent and how the resulting logistical issues can be tackled.20

Individualization does not only pertain to time variation but also to content variation once a learner gets beyond the foundational core curriculum. Here is where the construct of EPAs provides additional value to the CBME framework. Within the set of general EPAs that apply to a specialty, there are some EPAs that may be more specific to a given type of practice. Although all learners must become competent in all Core EPAs relevant to their entire practice domain, elective EPAs may be offered to allow them to focus their attention on areas they feel to be of critical importance in their anticipated future practice, maximizing the efficiency of their training time.

The next step is to move CBME beyond the education and training stages of physicians’ careers to focus on competency-based practice. Continuously striving to develop and improve one’s practice within the context of the challenges of the working environment should be the norm for all physicians.21

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Career Development and Transparency of Competence

Mastered EPAs constitute the building blocks of professional work. Building a dynamic portfolio of these EPAs requires (1) continued practice of those EPAs for which summative entrustment decisions have been made; (2) adaptation to enhanced standards of practice, reflecting up-to-date abilities if techniques and insights have evolved; (3) acquisition of new knowledge and skills leading to entrustment for additional EPAs in one’s field of practice; and (4) deliberately leaving behind those EPAs, beyond the requirements of the appropriate certifying bodies, that one is not practicing. Practice, and thus the EPAs that define a physician’s practice, will change. Technological innovations in health care (e.g., rapid advances in artificial intelligence22) will require physicians to adapt their practice. For instance, a physician may reconsider the need to memorize vast amounts of details and instead may use information technology to search for resources demonstrating best available evidence. Physicians may exhibit digital badges of their entrusted EPAs in a portfolio of credentials, to be visible for relevant parties (e.g., hospital administrators, credentialing organizations, regulatory bodies, medical and nursing staff, patients, insurers).23,24 Importantly, although EPAs provide a framework for integrating and assessing competencies, there are some competencies, such as practice-based learning and improvement, that are best assessed by a review of the physician’s practice data before and after an intervention.

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Visualizing the Education, Training, and Practice Continuum

The traditional Flexnerian medical school curriculum required learners to have a sound knowledge foundation before they began their clinical experience (see Figure 1, Panel A). In contrast, modern UME programs integrate the basic sciences and clinical experiences in the early years of medical school, thus smoothing the transitions within UME.25 This integrated approach of learning and practice, which gradually builds from the beginning of the curriculum, has been designated as an H to Z transition. Traditionally, there was a sharp horizontal divide between education and practice (which looked like the letter H; see Figure 1, Panel A), yet in more modern, integrated curricula, there is a gradual increase of clinical experience (which looks like the letter Z; see Figure 1, Panel B).26 Although the integration of learning and practice has become an established approach,27 it has not been applied across the continuum of education, training, and practice. Panel C in Figure 1 reflects a future in which learners not only gradually become practitioners, with supervision decreasing while responsibilities in patient care increase in breadth and depth, but learning also remains an integral part of practice.

Figure 1

Figure 1

Figure 2 depicts the EPA portfolio of a learner as she advances through medical school, residency, and practice. With her medical degree, she is trusted to perform a set of health care tasks without direct supervision at the start of her residency training. Once in residency, she may not practice some of these EPAs, so she no longer maintains the competence to practice those activities unsupervised. Many EPAs are expanded or combined into more comprehensive EPAs, and others are completely new. At the end of her GME training, she is ready to be entrusted with a new set of EPAs that do not require supervision. However, full expertise and mastery of complex EPAs will only be achieved, maintained, and renewed after continued deliberate practice over the course of her career. This process will hold for the majority of EPAs that she is ready to be entrusted with before the end of residency training, and which she will further strengthen throughout practice.

Figure 2

Figure 2

Advancing toward proficiency or expertise should be considered as pathways that award credit toward the quality improvement requirement in continuing certification. Entrustment for some EPAs may lose validity if they are not practiced or maintained, while the need for entrustment for new EPAs may emerge as biomedical science and technology advance or when a physician chooses new practice areas. A system of mentoring and/or peer observation and assessment could be integrated into the existing regulatory system. Once a practitioner becomes entrusted with a new professional activity, portfolios, such as those maintained by specialty boards, could be updated to reflect new EPA entrustment decisions.

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Addressing the Specificity of Credentials

Multiple communities of practicing physicians have asked for credentialing organizations to recognize niche areas of practice. Building dynamic portfolios of EPAs may fulfill such requests. In 2017, the American Board of Medical Specialties (ABMS) put into effect the first focused practice designation in adult hospital medicine. Doing so represented an opportunity and formalized a process for regulators to set standards for, assess, and recognize areas of additional expertise through certification.28,29 In the United States, ABMS and the American Osteopathic Association currently require that physicians pass an initial knowledge examination to receive the focused practice credential and interval examinations over their careers to maintain it. Although such exams may be appropriate to determine physicians’ knowledge related to select medical problems requiring specific cognitive or technical skills and affecting a moderate to large proportion of the population, some physicians are currently requesting this credential for either limited, niche practices or for carve-outs from the core work of a generalist.

Additionally, creating psychometrically sound examinations for small numbers of physicians in niche practices can be costly. Increasingly, periodic closed-book examinations for continuing certification, offered in secure testing centers, are being replaced with longitudinal online tests.30 Portfolio-documented workplace interventions are also being used to engage physicians longitudinally in local quality improvement efforts during which their skills can be demonstrated, observed, assessed, and improved over time.31 The Vision for the Future Commission, initiated by ABMS to evaluate certification, recently published their final report.32 One of their recommendations states that “continuing certification must change to incorporate longitudinal and other innovative formative assessment strategies that support learning, identify knowledge and skills gaps, and help diplomates stay current.”

The ability to harvest passively accumulated data from electronic health records would provide a rich source of information to characterize the safety and quality of physicians’ work. An integrated framework of EPAs, competencies (i.e., abilities), and milestones (i.e., brief narrative descriptions of performance levels across a developmental continuum) may provide an educationally sound, patient-centered, and cost-conscious pathway to recognize physicians with niche practices. Mentors and colleagues, qualified for these EPAs, would teach, supervise, and assess the learner or peer using observations, outcome data, and other data sources in a process managed with continuing professional development experts. Conversely, clinicians being reviewed would in turn review others in areas of their own expertise, ideally creating a mature professional community that upholds standards and in which everyone receives and provides feedback and guidance from and to others.

Determinations of competence could be submitted to a regulatory authority, or, if a sufficiently specific outcome is available, automated or centralized adjudications could be made.

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Other Considerations

The aim of CBME is to produce physicians who are capable of state-of-the-art, competency-based practice. Ensuring and advancing high-quality, safe patient care depends on an infrastructure for ongoing learning, assessment, and feedback. The current structure of medical education—with sequential and separated rather than integrated programs; one-size-fits-all, fixed lengths of training; additional training sequences of prescribed duration for subspecialties; and ever-increasing costs to the individual, the profession, and the public—appears unsustainable. However, educators now can define the EPAs needed for physicians within highly diverse practice types, map them to the competencies that are critical to making an entrustment decision, and build curricula and assessments that foster learning experiences with progressive autonomy.

Learners should start contributing to patient care with supervision as soon as they have been observed and deemed ready for those specific responsibilities. While they progress through more specialized training, their responsibilities should increase. Learners will not be experts after they complete residency and fellowship training, but they will have passed a threshold for unsupervised practice at that point. They will become expert only with time and deliberate practice. In a health care system in which all professionals are simultaneously lifelong learners and teachers for different competency expectations, the pivotal moments of completing a degree and receiving a specialty certification become less significant.

A centralized approach to competency management over the career of a physician will be necessary. Key to such a system would be a portfolio that showed physicians’ scopes of practice, defined by continuously valid EPAs at any given moment in the course of their professional life. Through its professional societies, education associations, and certifying boards, to name a few, each specialty community will need to develop a process that could be embedded in an existing system for tracking credentials. This process must be user-friendly, autopopulated by primary sources, and kept up-to-date with current profiles of individual physicians’ credentials.

This vision may seem like a distant future, but it is the direction that we believe will best serve the medical profession if the quadruple aim of better care, better health, containable costs, and resilient physicians is to be attained. Health care is changing rapidly, and educational programs need to evolve to meet the changing needs of physicians so that they may ultimately meet the changing needs of patients.

Finally, physicians’ mindsets will need to change. Their guiding principle should be that professional practice requires ongoing learning and engagement, which must be conveyed throughout the continuum, from admission to medical school until retirement. Making the importance of lifelong learning and professional development explicit in teaching about professional responsibilities is key if educators want new members of the profession to value learning. The primary aim of our proposal in this article is to encourage the personalization of educational interventions that maximize efficiency and effectiveness and, at the same time, promote motivation and self-determination in physicians to meet evolving standards of practice because they see these standards as meaningful rather than regulatory.33 We anticipate that this exciting evolution from competency-based education to competency-based practice is inevitable. Ultimately, the collective ability to self-regulate and adapt to the changing needs of the medical community will be a positive reflection on the profession and its commitment to providing quality care for the patients and families that physicians are privileged to serve.

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Acknowledgments:

The authors wish to thank Dr. Graham T. McMahon of the Accreditation Council for Continuing Medical Education for his extensive comments and suggestions regarding earlier versions of this article.

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