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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_112_библиотеки_им_акад_М_И_Перельмана
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colleagues laid out benefits of coproduction in medical education,
noting: “. . . like the relationship between patients and providers, the
relationship between learner and teacher requires the integrated
expertise of each nested in the context of their system, community,
and society to optimize outcomes.”85 Coproduction is a bidirectional
interaction between the learner and the training program.
Coproduction fuels a cyclical, ongoing process. Fig. 3.7 highlights
how incorporating coproduction as part of learning cycles along a
trajectory can empower learners to view their own professional
development as an ongoing, coproduced, iterative assessment
process. Fig. 3.8 brings together the key concepts of professional
development learning curves, programmatic assessment, and
iterative learning cycles using a coproduction approach.
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FIGS. 3.7 and 3.8. Medical training during the undergraduate medical
education and graduate medical education years is an intensely
developmental and iterative process. Each learner will experience
different trajectories and must be an active partner with agency to
coproduce their own educational experiences, including assessment. Fig.
3.7 displays key stages and questions in the coproduction cycle that must
be iteratively implemented as part of the longitudinal growth curve shown
in Fig. 3.8.
Adapted from Englander and colleagues, Table 3.5 compares and
contrasts traditional assessment approaches to one using
coproduction. UME and GME programs can use this framework to
improve their assessment programs and empower learners to strive
for better outcomes.85 However, medical education has struggled to
create psychologically safe environments for learners. This is
especially true for URiM learners who often must overcome
stereotype threats and impostor syndrome. Partnering with learners
to understand and attend to their lived experiences with current and
past assessment activities will help programs improve assessment
and confront and reduce bias in assessment. Program leaders will
need to inform learners about coproduction, recognize and reward
the learner role in coproduction, and create system changes to enable
learners to receive more timely feedback and assessments through
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dashboards and rich information systems. Table 3.5 provides a
summary of the key assessment roles of program leadership, faculty,
and learners.
Table 3.5
Traditional Versus Coproduction Models of Assessment in Medical
Education
System
variable
Traditional/Hierarchical Coproduction
Logic
dominant
model
“Goods” model.
Learner viewed as
“product” where
assessment is done
primarily to ensure that
the “product” meets
minimal standards for
release to the next stage
of a career.
“Service” model.
Learner viewed as health
professional ultimately
providing service to
others. A service model
requires a coproduction
mindset because services
are, by definition, always
coproduced between
two parties.
Primary
driver
Teacher is primary
assessor.
Learner(s)–teacher
partnership designs,
performs, and interprets
assessments.
Focus Emphasis on
summative,
retrospective
assessments using
rating scales that
“quantify” the learner
(e.g., end-of-rotation
evaluations or grades).
Increased emphasis on
narratively rich
assessments that
demonstrate
developmental
improvement in which
learner contributes to
their assessments.
Assessments
deemphasize
overreliance on
quantitative rating
scales.
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Information
“ownership”
Medical school,
residency, or fellowship
program owns and
controls assessment
information.
Learners own their
assessment data that are
transportable to new
schools/programs.
“Nothing about me
without me.” The
institution is a trusted
custodian of assessment
data and uses the
assessment data in
aggregate (with consent
from the learner) to
improve curriculum and
assessment.
Relationship
between
professionals
Each assessor provides
assessment in isolation
and assessment data
from multiple
professionals is often
lacking, of poor quality,
or not incorporated into
a learning plan for
improvement.
Assessments from other
health professionals
mostly used to identify
problems and
“outliers.”
Assessment data from
multiple health
professionals is
integrated into a more
holistic picture of
abilities in all
competencies using a
developmental mindset.
Connections
between
aspects of
the system
Abrupt transitions
between phases of
training (e.g., medical
school to residency, to
fellowship, to practice).
No sharing (“feedforward”) of assessment
data is performed,
encouraged, or
supported.
Clear transitions with
systematic “warm
handoffs.” Sharing
assessment data to
support tailored learning
for professional
development across the
continuum and variable
time-based training
based on competence
and learner needs.
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Improvement
model
Limited system
perspective—blame and
punishment model.
Focused on “weeding”
out “bad” or
underperforming
learners.
Continuous
improvement of the
assessment program
based on input from all
stakeholders to support
professional
development.
Adapted from Englander R, Holmboe E, Batalden P, et al. Coproducing health professions
education: A prerequisite to coproducing health care services? Acad Med. 2020;95(7):1006–
1013. doi:10.1097/ACM.0000000000003137.
In summary, a robust program of assessment must be coproduced
and include multiple, integrated assessment methods and tools
performed as a series of learning-assessment cycles conducted
longitudinally over the course of the entire training program. A
coproduced assessment program should be guided by informed
group judgment and decision-making, and actively involve the
learner embracing the philosophy of coproduction across the medical
education continuum.
Putting It All Together: Implementation
Science and Programmatic
Assessment
While developing new assessment approaches and tools remains
necessary, we already possess multiple, useful assessment
approaches and tools. Therefore, going forward medical education
should focus primarily on how to better use our existing wealth of
assessment approaches. As program leaders evolve their assessment
approaches, lessons and tools from implementation science can help.
Ultimately, designing and running training programs and their
system of assessment is not about a destination, but rather an
ongoing developmental journey to continuously improve
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educational approaches (e.g., learning environment, curriculum, and
assessment programs as all are integrated) as biological, medical,
health system, and educational sciences evolve. By default, change
and continuous improvement is a messy process. Medical education
must embrace implementation science to support transformation in
assessment, including the elimination of harmful bias.
Medical education programs are embedded within complex
educational and clinical systems. The hallmark of complex systems
are the interdependencies and interactions between all the “parts and
components” with people (i.e., health professions faculty, program
directors, program coordinators, and learners) being the most
important components of the system, as noted earlier. When
implementing a change, or new interventions in an assessment
program, training program leadership must attend to key aspects of
implementation.
Lessons and tools from implementation science can help
educational leaders determine how to implement assessment
programs and specific assessments. For example, the Consolidated
Framework for Implementation Research (CFIR) can guide
implementation and continuous quality improvement efforts in
assessment.86 The CFIR explicitly calls attention to five components:
the conditions and characteristics of the outer setting (e.g.,
institutional social contexts); the inner setting (e.g., training program
administrative support); the characteristics of the assessment
approach (e.g., complexity in using the assessment, learner
perceptions); the individuals involved (e.g., do they have agency and
self-efficacy around the assessment; and the process (e.g., capacity of
the program for change, presence of change agents and opinion
leaders). Yaghmour and colleagues applied this framework to better
understand the developmental change journey of residency
programs implementing Milestones and uncovered at least three
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program-level stages.40 In 2017, all residencies at Queens University
Canada implemented an outcomes-based, time-variable approach
and shared their early implementation results using rapid cycle
evaluations. They uncovered several expected and unexpected
challenges, a common phenomenon with major system changes.
87
Both of these studies highlight how using implementation
frameworks to guide the evaluation of large-scale initiatives can
produce deeper insights into programmatic change. Appendix 3.2
provides an example of a CFIR template for implementing the
revised Milestones 2.0 (see Chapter 1) for specialty training in the
United States.
Conclusion
Medical education training programs already possess a wealth of
assessment approaches and tools. Now we must commit to using
these tools and approaches more effectively within programs of
assessment (i.e., programmatic assessment) using systems thinking
to continuously improve. There is much we can do now to improve
assessment practices (Box 3.2). This requires creating educational
systems that allow the development, implementation, and
sustainment of assessment programs. Assessment must be a high
priority and not treated as an adjunct or afterthought in an
educational program. Ideally, the purpose of assessment aligns with
learning (assessment drives learning and learning drives the right
type of assessments). Unfortunately, that is still not the situation in
the majority of health professions education programs. Assessment is
too often designed to incentivize competition where the quality of
the assessment is defined by how well it can distinguish
(discriminate) performance among learners (ranking and normative
mindset) instead of ensuring that all learners attain a high level of
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performance (criterion and mastery mindset). The uncomfortable
reality of the ranking type of assessment system finds its origins in
psychological testing that had and still has the primary purpose of
telling people apart: normal from abnormal, suited for the position
versus unsuitable for the position, et cetera. But in education the
purpose is not to tell whether Jane is better than Jim but to ensure
that Jane and Jim become the best health professional they can be.
When our predominant conceptualization of the role of assessment
in education is one of measurement, grading, selection, and
discrimination, its value proposition conflicts with the primary value
proposition of education. Programmatic assessment must be viewed,
using a systems lens, as an intrinsic and inseparable component of
education and therefore as inseparable from medical education’s core
value proposition to improve health and healthcare.
Box 3.2.
A (Partial) List of Actions Medical Education
Programs Can Do Now to Improve Assessment
1. Ensure the majority of assessments are
developmentally designed and focused.
2. Use assessment data to investigate, understand, and
address sources of bias in the assessment program.
a. Seek to understand the effects of program culture
and the institutional learning environment on
learners’ professional development.
3. Develop and implement programmatic assessment.
a. Emphasize workplace-based assessments for the purpose
of supporting learners’ professional development.
b. Embrace narrative assessments.
c. Use learning analytics to support learners’ professional
development and the continuous improvement of the
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assessment program.
4. Leverage existing technologies to improve assessments (e.g.,
natural language processing, smartphone apps, etc.).
5. Investigate, understand, and address sources of unwarranted
variation in the assessment program.
6. Explicitly define the assessment roles of all faculty (physicians
and other health professionals) and learners.
7. Invest in training of faculty and learners in assessment.
8. Leverage coproduction to support assessment practices and
learners’ professional development.
9. Use translational and implementation science to build, revise,
and improve assessment programs and practices.
10. Honestly assess and confront inertia in changing assessment
practices.
Educational environments need to have the time and the resources
and be designed so that learners and all faculty assessors have
enough time working together to enable effective assessment and
feedback to occur. This requires confronting the uncomfortable
inertia that has persistently limited improvement and change in
programmatic assessment, especially around issues of structural bias
and racism. Change will require humility to recognize what is not
working and concerted effort to address weaknesses and gaps within
our assessment systems, including the regulatory components of
professional assessment. Effective and efficient programmatic
assessment is within reach of all health professions education.
88–92
We have strong assessment science to make a difference in the lives
of our learners and patients through better assessment practices
grounded in a developmental, coproduction mindset embedded in
integrated, well-designed programs of assessment.
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Acknowledgments
I wish to thank Dr. Lambert Schuwirth for his helpful review,
suggestions, and edits.
Parts of this chapter were originally produced for a Macy
Foundation white paper by E.S. Holmboe, N. Osman, C. Murphy,
and J. Kogan.
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