Barriers to CBME in a Learning Program

Advantages of CBME

CBME has emerged as a core strategy to educate and assess the next generation of physicians. Its advantages include:

• Focus on Outcomes and Learner Achievement: Emphasizes what students need to be able to do upon graduation.
• Multifaceted Assessment: Uses both formative and summative approaches to comprehensively evaluate competencies.
• Flexible, Time-Independent Curriculum: Allows students to progress at their own pace based on competency achievement.
• Increased Accountability: Provides a common language and shared expectations for education, assessment, and regulation among stakeholders.

Key Challenges in CBME Implementation 

CBME brings notable benefits to medical training. It provides clear, specific learning outcomes for crucial clinical competencies and allows students to progress at their own pace, personalizing the learning experience. Moreover, CBME's emphasis on competency-based assessment offers a more accurate evaluation of students' abilities.

However, the implementation of CBME, particularly in large and complex educational programs, is not without challenges. It demands substantial organizational changes and raises several concerns. These challenges include:

1. Curriculum Redesign

   • Competency Framework: Detailed competencies for each discipline.
   • Modular Structure: Curriculum focused on specific competencies.
   • Integration: Combining clinical and basic sciences.

2. Faculty Development

   • Training Programs: Educating faculty on CBME principles.
   • Change Management: Supporting faculty with workshops and seminars.

3. Assessment Methods

   • Competency Assessments: Tools like OSCEs and portfolios.
   • Continuous Feedback: Systems for ongoing formative feedback.
   • Reductionist Approaches: Concerns about overly simplistic assessments.

4. Technological Infrastructure

   • Learning Management Systems: Supporting competency tracking.
   • Data Analytics: Monitoring progress and identifying gaps.

5. Administrative Support

   • Program Coordination: Appointing CBME coordinators.
   • Support Services: Enhancing administrative support.
   • Increased Administrative Requirements: Managing additional complexities.

6. Clinical Training Sites

   • Partnerships: Strengthening clinical site relationships.
   • Supervision and Mentorship: Training clinical supervisors.

7. Quality Assurance and Accreditation

   • Accreditation Standards: Aligning with standards.
   • Program Evaluation: Continuous curriculum evaluation.

8. Student Support

   • Advising and Mentorship: Helping students navigate CBME.
   • Remediation Programs: Support for struggling students.

Pandemic's Influence on Medical Education

COVID-19 forced rapid adaptations, some with long-term benefits. As we consider the history of CBME, the disruption to health professions education caused by COVID-19, and the impact of the pandemic on CBME, it is important to identify the gaps uncovered through our collective experience:

• Virtual Simulation and Telehealth: New modalities, initially adopted out of necessity, may offer advantages in preparing students for patient care.
• Assessment and Grading: Some institutions reported improved student performance on examinations administered prior to clinical immersion. Many schools also transitioned to pass/fail grading systems due to limited observation time.
• Competency Focus: The pandemic reinforced the importance of competency attainment over time-based progression, aligning with CBME principles.

CBME in Graduate Medical Education

CBME is steadily gaining global momentum, though its adoption varies across regions and institutions. Leading the charge are influential organizations like the Accreditation Council for Graduate Medical Education (ACGME) in the United States and the Royal College of Physicians and Surgeons of Canada.

The ACGME's Milestones 2.0 initiative has been instrumental in promoting competency-based progression. Interestingly, the recent pandemic served as a catalyst for this shift. It introduced new avenues for observation, such as telehealth, and fostered increased interprofessional collaboration. These unexpected developments have further underscored the relevance and adaptability of CBME in modern medical education.

Future Directions and Gaps

While CBME has made significant strides, several areas require ongoing attention and improvement:

1. Improved Assessment

   • Complex Competencies: Better tools and methods are needed to assess complex competencies such as professionalism, communication, and interprofessional teamwork. Current assessments may be too simplistic, not capturing the full scope of these skills.
   • Innovative Assessment Methods: Exploring alternatives to traditional testing, such as progress testing, which assesses learners' knowledge growth over time rather than at specific intervals.

2. Rethinking Evaluation Methods

   • End-of-Rotation Testing: Moving away from traditional end-of-rotation exams to more continuous and integrated forms of assessment. This can include frequent low-stakes testing that provides ongoing feedback and better reflects a learner’s development.
   • Longitudinal Assessment: Implementing longitudinal assessment approaches that monitor students' progression and competencies throughout their education, offering a more comprehensive picture of their growth.

3. Faculty Development

   • Comprehensive Training Programs: Developing extensive training programs for faculty to enhance their understanding of CBME principles, assessment methods, and educational strategies. This ensures that faculty are well-prepared to support CBME implementation.
   • Ongoing Professional Development: Creating continuous professional development opportunities to keep faculty updated on the latest advancements in CBME and educational methodologies.

4. Technological Advancements

   • Enhanced Learning Management Systems: Upgrading LMS to better support competency tracking, personalized learning paths, and electronic portfolios.
   • Data Analytics: Utilizing advanced data analytics to monitor student progress, identify gaps in competency achievement, and tailor educational interventions accordingly.