Improving Graduate Medical Education Through Faculty Empowerment Instead of Detailed Guidelines

Abstract

Calls for improvement and reform in graduate medical education (GME) have led to more detail in educational and curricular guidelines. The current level of detail in curriculum guidelines for GME training programs is high, encompassing, for example, competency frameworks, entrustable professional activities, and milestones. In addition, faculty must employ an increasing number of assessment tools and elaborate portfolio systems for their residents. It is questionable whether any further increase in curriculum detail and assessment formats leads to better GME programs. Focusing on this type of system development may even lead to less engaged faculty if faculty are not encouraged to use their own professional judgment and creativity for teaching residents. Therefore, faculty members must be empowered to engage in curricular innovation, since system development alone will not result in better training programs. Raising faculty members’ awareness of their virtues and value as teachers and involving them in the debate about how GME can be enhanced might increase their engagement in resident training.

Successful education depends on policies based on flexibility, creativity, teacher professionalism, and trust.¹ Adding too much detail in guidelines for graduate medical education (GME) might create less engaged faculty since they are not encouraged to use their own professional strengths for teaching residents.² Therefore, as we develop GME guidelines, we should focus on a balance between educational standards and encouraging and empowering faculty to make use of their professional judgment and creativity.

Why GME Will Not Benefit From More Detailed Guidelines

Within GME guidelines, we notice an increasing level of detail that outlines how GME should be designed and implemented.³ Competency frameworks are frequently used for designing curricula. Trainers and trainees have indicated that competency frameworks are too theoretical to apply in daily practice.⁴ Therefore, several assessment tools are used to measure competence, but they focus on only a limited area of competence and lack a holistic overview. To bridge this gap between theory and integrated practice, many GME programs worldwide introduced entrustable professional activities. In addition, competencies and milestones were introduced to assist faculty even further in assessing residents’ competence and to help residents in discovering what they should learn to become the professional they aim to be. These examples show the increase of detail and the number of concepts that have been introduced in GME over the last few years.⁵ GME is shifting toward more detailed curricula with comprehensive competency frameworks, prescriptive portfolios, and an increasing number of assessment tools.

The increasing complexity of medical specialties, the need for high-value care, and the focus on quality improvement seem to go hand-in-hand with the constant development of new curricula and assessment tools. This shift can be regarded as a sign of the professionalization of residency training, but further increases in prescription and bureaucracy can mean less room for professional vision, judgment, and creativity as well. This development might put the autonomy and engagement of faculty at risk. Besides, there is also a risk for the learning process. The more detailed the descriptions of what a learner should learn, whether it is specified in terms of competencies or learning goals, the more instrumentalist the curriculum becomes, emphasizing the development of a workforce with specific practical skills. Although practical skills are of high importance for medical specialists, present-day society requires a human-oriented approach to health care with an increased attention on the patients’ personal and contextual characteristics as well.⁶ Therefore, an instrumentalist curriculum may not be optimal in GME.

Two Illustrations and the Need for Balance

An illustration of the growing detail within GME development is the well-known CanMEDS movement.⁷ Since its formal adoption by the Royal College of Physicians and Surgeons of Canada in 1996, CanMEDS has become the world’s most widely accepted and applied competency framework for physicians. It is based on empirical research, sound education principles, and broad stakeholder consultation. Regular updates are supposedly essential for the CanMEDS Framework’s ongoing success, which is why it has been updated twice since it was first developed—once in 2005 and again in 2015. By our count, what started as a clear overview of 7 roles with 23 competencies has expanded to a framework that consists of 7 roles, 27 competencies, 89 enabling competencies, and 847 milestones (Table 1).⁸ The addition of CanMEDS milestones in 2015 was meant to assist faculty in navigating a trainee’s transition from one training stage to the next.⁹

Table 1: The Increasing Number of Roles, Competencies, and Milestones in the CanMEDS Framework, 1996–2015^{8 a}

Finding a level of detail that provides both clear expectations and the opportunity for professional creativity is key when it comes to developing a feasible curriculum. We argue that, within the CanMEDS movement, the description of abilities in each stage has become too detailed. We believe that detailed prescription takes a heavy toll. Developing more enabling competencies or milestones will only limit the possibilities for faculty to make use of their own judgment and creativity in training residents.¹⁰

This movement toward more detail is not unique for competency frameworks. We see a similar development, for instance, in the number of assessment tools. Since the decline of the one-on-one master–apprentice learning paradigm, there has been a rapid and extensive change in the way assessment is conducted in medical education. Two well-known and widely used tools are the mini-clinical evaluation exercise (mini-CEX) and the objective structured clinical examination. But the development of assessment tools did not stop there. Critically appraised topics, multisource feedback, structured entrustment decisions—these are all useful tools for giving trainees standardized feedback. However, each tool has its own extensive guidelines. Keeping up with all the requirements for using these tools leaves few options for nonstandardized feedback in which faculty may excel.

The CanMEDS and assessment tool examples show the current trend in GME: adjusting the system or adding more detail about how to use a system correctly. However, adding more detail or reforming systems often does not lead to the desired effects.¹¹ Such changes may be perceived as a reason for implementing yet another reform or adding even more detail, and so on.

Improving GME by Empowering Faculty

When constant reforms do not lead to the intended outcomes, it is questionable whether new reforms will succeed. Designing new competencies, creating more milestones, and developing other assessment tools may all be intended to assist faculty in constructing a better residency program. However, all this detail can lead to passive, less engaged faculty since, with more detailed requirements, faculty are not encouraged to use their own professional judgment and creativity for teaching residents. Successful education policies in Finland show that steady improvement in student learning has been attained through policies based on flexibility, creativity, teacher professionalism, and trusting faculty.¹ We make a plea for such an approach in GME. As Koksma and Kremer put it, “the problem starts when people see their models as true and turn their back on the complexity of the real world.”¹² We advocate caution when it comes to relying on more detailed guidelines for further improvement of GME. In our opinion, training will not benefit from creating more or other educational systems and tools within GME. On the contrary, the chance of meaningful education will increase if faculty members are given enough freedom to be empowered and encouraged to make use of their professional strengths.

Should we leave all decisions to faculty and trust their professional strengths without establishing standards and tools to assess learners? No, many such tools have improved and professionalized GME and, especially in a time when there is a need for more flexibility and personalization of training programs, we need well-formulated curriculum guidelines. Moreover, subjects related to systems-based practice (e.g., delivering high-value, cost-conscious care) need guidance, but no prescription¹³ because we should cherish the professional capabilities of faculty members as much as we value guidelines and standards.

In education in general, teachers who once were proud to be seen as professionals feel more like operatives due to the increasing burden of administrative work.¹⁰ If new curricula and assessment tools in GME keep generating more administrative work, GME faculty must also fear the same fate. Faculty who were engaged in curriculum creation experienced growth in their professional role and more collaboration with colleagues, even though this engagement takes time and requires experimentation.¹⁴ Therefore, it is advisable to embrace the tools we already have in GME, but to focus mainly on empowering faculty and giving them time and opportunity for their own way of teaching rather than making existing guidelines even more detailed. Koksma and Kremer explain it as follows: “Too rigidly defined objectives inhibit performance, especially when those working toward the goals feel that they will not be achieved.”¹² Hence, when our learners need to be trained in new content or competencies, we must investigate how this can be done within our existing well-developed curricular frameworks. Stricter guidelines and more detail in frameworks will most likely lead to less engaged faculty. Therefore, we need more trust in the professional strengths of academically trained medical professionals. Using a prescribed set of guiding principles, such as the existing competency frameworks, as a foundation, faculty may develop their own style by gaining experience, reflecting on it, discussing with colleagues, and developing a shared goal that is fit for their context.¹⁵ Faculty development sessions can be of high importance in facilitating these moments of reflection and discussion between faculty.

We make a strong plea for stimulating a debate between faculty members about how GME can be enhanced, while raising faculty members’ awareness of their virtues and value as teachers. Faculty development can contribute in creating learning communities; subsequently, faculty will be empowered to improve GME, not because they are forced to do so by educational systems, but because they are respected for their professional judgment and creativity.