Medical educators live in a world of uncertainty. Within graduate medical education (also called “postgraduate medical education” depending on the jurisdiction; we will use graduate medical education to include both), we are currently experiencing a climate of disruptive change. In addition to the worldwide transformations occurring in medical education, patient empowerment, technological advances,1 reduced duty hours for trainees,2 an increased focus on workplace safety,3 and the use of big data have all entered the medical realm.4,5 Although competency-based education has been present for many decades in higher education and other professional environments (e.g., NASA, the military, the aviation and nuclear industries), competency-based medical education (CBME) has only recently emerged as a possible solution to many of the challenges facing medical training today.6 Currently, many faculty and institutional leaders are reflecting on the “whys,” or drivers, prompting the need for change to our complex, often rigid, and expensive systems of physician training. Others have clearly outlined the strong value proposition for CBME, including societal accountability,7 transparency of competency attainment,8,9 trainee development and wellness,10,11 and patient safety, to name just a few.11 For many, it is obvious that the current system is no longer adequate to provide optimal physician training within the dynamic, ever-changing world where we live.
CBME is the prevailing new model of medical training across much of the world. The challenges of implementation ahead, especially given the simultaneous exploration of various CBME models across jurisdictions, are immense. Multiple perspectives, ideas, concepts, frameworks, and assumptions surround us, but there is no evident truth.12 Many questions remain regarding the evidence required to pursue the massive undertaking of transforming graduate medical education across the world. Understandably, there has been much pushback and resistance at many levels of leadership. Questions about the costs of local implementation, whether CBME is actually a superior framework, what unintended consequences of this new educational model might emerge, and who is most responsible for leading the innovation and implementation processes are commonplace amongst medical educators, researchers, and leaders.12–16
According to some, “we are swimming in a tsunami of change” and the best way forward remains unclear.17 Discomfort arises when engaging with the elements of any good change process, such as emergent strategy, uncertainty, flexibility, messiness, disruption, leadership, multiple perspectives, shared power, and dialogue. In the traditional world of medicine where organization, order, hierarchical structures, responsibility, and accountability are seen as fundamental priorities, many physician leaders struggle to embrace these elements of successful change for fear of ensuing chaos and loss of control. And yet, embracing emergent strategies for CBME implementation within a distributed leadership model is precisely what is needed. This is supported by the body of evidence provided by complex adaptive systems and the psychology of change literature.18–20
To be clear, CBME is not unique as a change initiative but is a transformative change in medical education. Acknowledging that the most powerful innovations often happen at the “intersection” of industries, cultures, and disciplines, medical education leaders need to draw on the important work of others. Our purpose is to support the uptake of evidence-based change practices developed in other fields (psychology, neuroscience, behavioral economics, business leadership, human systems design, and sociology) to inform the change process of CBME.21
Leading change well in the complex system of medical education is critical to the health of our organizations and success of our training systems. Historically, within graduate medical education, program directors have shouldered the burden of leading change related to their specialties but have not themselves been trained to be change leaders beyond the realm of curricular renewal, assessment practices, and basic quality improvement22—with some rare exceptions. In the new climate of disruptive change, the craft of change facilitators and the presence of local leaders are needed more than ever. For implementation success, many additional education champions must be mobilized to increase the potential upside of CBME and achieve the desired return on investment.
Moving forward, we propose an evidence-based way of thinking and acting to both prepare our community for the transformative change of CBME and support us through emergent adaptations during the initial years of implementation. Although largely attributed to the Canadian experience with the rollout of the Royal College of Physicians and Surgeons of Canada Competence by Design initiative, these recommendations are intended to inform CBME implementation in any context. We propose 3 priorities: (1) engage, entrust, and empower education leaders by increasing shared ownership of the CBME innovation23; (2) better prepare education professionals in leadership and transformational change techniques in the complex system of medical education; and (3) leverage the wider community of practice to maximize local CBME customization.
Engage, Entrust, and Empower Stakeholders to Increase Shared Ownership of CBME Innovation
A key principle of leading change is that the quality of the change process needs to align with the essence of the desired change.24,25 Some of the transformative change associated with CBME innovation is about creating a more participative and inclusive culture in medical education. Hence, our design and leadership of that change should mirror those participatory and inclusive qualities by engaging, entrusting, and empowering medical education professionals to lead. Centralized leaders of the CBME process can optimize outcomes by being prepared to learn together with professional stakeholders and to assist diverse, locally considered approaches to adopting CBME.23
Transformative change begins when the originators engage stakeholders to take ownership of the innovation.23 These feelings of ownership grow when stakeholders shape the rationale for change from their unique perspectives (e.g., how it impacts them or aligns with their goals and context). Ultimately, they need to meaningfully connect with the change and begin to envisage what it will mean for them within local contexts. Throughout this process, the change originators need to embrace resistance, doubt, and conscientious objections and value them for the opportunity offered by diverse perspectives to forge stronger solutions. Conversations about the lack of evidence to support transformative change may arise. If they do, redirecting these conversations toward an implementation science approach that encourages us to build evidence as we implement change is proving to be advantageous.26–28 Learning together is the key to a high-quality implementation process.29
Just as supervising physicians entrust trainees to care for patients, so must centralized CBME leaders entrust stakeholders to create local CBME implementation solutions. This is a challenging process for hierarchical leadership structures characterized by top-down, centralized control, often steeped in tradition and slow to adapt. For these leaders, abandoning clearly defined goals in favor of embracing diverse perspectives in which learning and adapting together is iterative presents new challenges.29 However, a distributed power structure that entrusts and empowers local leaders to shape innovation, with ongoing centralized support and guidance, will generate the experience of ownership and pride of accomplishment. From our experience, CBME adoption increases as educational leaders work with program stakeholders to customize CBME innovations to local contexts, learn from challenges and successes, and implement adaptive course corrections in a timely manner.22
Better Prepare Professionals to Lead Change in the Complex System of Medical Education
The path to change is complex, disruptive, uncomfortable, and iterative, with the desired outcome(s) often taking far longer than expected. Consequently, leading change demands the capacity to deal with interpersonal, relational, and group dynamics. However, rarely have medical education leaders been formally prepared to lead change in this way. While hardworking and devoted, they are often unaware of vital theories and practices that can inform approaches required for CBME.21,30,31 They need practical training and actionable strategies to fulfill myriad requirements for CBME innovation, such as defining the rationale; enlisting the change team, engaging champions, and acquiring additional resources; building readiness through both faculty and resident engagement and development; supporting and coaching stakeholders throughout CBME implementation; and making progress visible to sustain energy and motivation required for the desired culture shift.32–34
Transformative change takes time and requires cultivating a shared mental model among stakeholders that becomes the path for change.22 By empowering action through negotiation, influence, and dialogue, stakeholders assume ownership of the innovation, essentially reframing change as their involvement in customizing the innovation to their context. Change is more successful when it is done by us and with us, and not to us. Embracing this approach requires more investment on the part of change leaders. Influencing stakeholders to cocreate meaningful change within their local context reduces threat responses and enables stakeholders to embrace CBME as an opportunity for collective improvement and increased trust.31
Building a movement of change leaders for CBME requires support and collaboration not only within institutions but also between institutions. In Canada, national and faculty leaders are already developing the structures, processes, and mechanisms (CBME committees locally, CBME leads nationally) to develop best practices, connections, and sharing of resources.14,35,36 Central and local funding opportunities will create a movement through shared training models, best practices, and lessons learned. Priority initiatives from the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada, such as strategic grants, have enabled cross-pollination among institutions and improved stakeholder engagement within institutions.15,37,38 As a result, this support effectively accelerates the diffusion of the CBME innovation for everyone.
Leverage the Wider Community of Practice to Maximize Local CBME Customization
Putting guidelines into practice is most successful when professionals are afforded room to shape the implementation in their local context. Although some strategic guidance should be provided to professionals both leading and engaged in implementing change, too much rigidity risks suffocating stakeholders’ motivation, creativity, and commitment.39
Education professionals must have ownership of their training programs within their individual contexts. Putting CBME into practice involves many new concepts, program changes, and customization at the frontlines of clinical care. There simply is no one-size-fits-all approach. People need the freedom and agency to act and adapt to their unique context.40 This approach often creates tension with the need for national or jurisdictional standards and benchmarks. The degree of uniformity necessary for a successful CBME launch is hotly debated. To be successful, education leaders must collaborate across as many programs and contexts as possible to share, refine, and adopt best practices of implementation. Creating new communities for shared leadership, coproduction, and learning within institutions must occur outside of traditional specialty and/or institutional silos (e.g., CBME steering committees and expanded resident networks at the local level).41 Only in this manner can the lived experiences of CBME be brought forward to enhance the system overall; through this freedom to experiment, confidence in the eventual model will come.
Creating a coalition of CBME stakeholders will generate and mobilize a social movement for transformation. A principle at the heart of coproduction is that, “People own and support what they create.”42 When stakeholders participate in designing, planning, and adapting the change to fit their context, the change initiative builds momentum. Empowering people to make CBME their own and allowing the change to be customized, remixed, and/or reshaped promote optimal implementation of CBME theory into local contexts.40 No stakeholder involvement means no stakeholder commitment. All stakeholders must be given power in shaping the future by engaging them throughout the design, implementation, and growth processes. The more complex the change, the more local involvement and customization are required.
Implementation requires shared leadership and building capacity at multiple levels within individual institutions. These processes should be supported but cannot be implemented by central power structures alone. Change must be led from within by trusted faces and peers. It requires creating an expanded community of frontline program leaders (faculty, resident, administrative) at each site, and within each program, to realize the vision of CBME implementation. Creating leadership capacity involves identifying new education champions, enabling them to share and celebrate their progress stories, providing training opportunities in change leadership, building relationships, fostering cross-collaboration amongst education leaders, and building communities of learning that can inform meaningful forward progress.43
Implementing complex change in medical education requires guidance at a tactical level from central CBME leaders, committed stakeholder investment based on entrustment and sufficient room for local diversity, patience with extant uncertainty, creation of expanded networks of shared leadership, tolerance for emergent strategies, and widespread leadership development in the realm of implementation science. There is no guarantee, certainty, or fixed model. Navigating the turbulent waters of transformational change tests our leadership structures and brings opportunities for learning from experience, reform, and renewal at all levels of the medical education training system. Collectively, we are all engaged in a generative call to action. What are each of our roles? How can we contribute as medical educators, leaders, and researchers to further this mission? How can we leverage resources and experiences to facilitate collaboration and communities of practice at all levels? How can we build capacity and multiply? These are just a few of the many questions worth asking. The fundamentals of change leadership suggest that we share power, instill trust through relationship building and coproduction, and build a wider community of emergent leaders committed to improvement. In this mission, we need full participation from all stakeholders. Adopting the priorities we discuss here may encourage stakeholder involvement and enable CBME to fully bridge the gap from theory to practice.
The authors acknowledge all who are working collaboratively to improve medical education and applying evidence-based change practices to help advance the mission.
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