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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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had been dominating training in the previous decades. The
other feature is the intention to better monitor doctors in
training and to ensure that they meet predefined competency
standards upon graduation to unsupervised practice.
23–28
Several major reports and initiatives have sought to move
CBME toward broader implementation. The International
CBME Collaborators (ICBME), a group of medical educators
and leaders convened by the RCPSC, produced in 2010 an
initial series of articles on the history, definitions and
concepts, and challenges to implementation of CBME,
including needed changes to assessment, across the
continuum of medical training.
29–31
That same year, Frenk
and a group of international leaders published an influential
position paper in The Lancet on the need to accelerate
transformation in medical education, grounded in the
principles of CBME.12 The Carnegie Foundation, on the 100th
anniversary of the Flexner report (1910), released
recommendations for medical education that embraced many
of the key principles and goals of CBME.16 Finally, the
ICBME released a second series of articles on evolving
concepts and recommendations for CBME based on a
growing body of experience with CBME implementation. All
of these reports have highlighted the critical and continued
need for better assessment.
32–39
The primary purpose of this third edition is to provide
practical guidance to educators and program leaders on the
frontlines for building and implementing better procedures,
programs, and systems of assessment, using the best
evidence and information available. Assessment is essential
for effective learning and for achieving desired educational
and clinical outcomes. As the adage goes, assessment drives
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learning and learning should drive the right form of
assessment, all connected to the ultimate outcome of
achieving the Quadruple Aim (Fig. 1.1).
FIG. 1.1 The Quadruple Aim.
CBME represents the latest phase of what should be a
continuous commitment to improve educational programs
and, by extension, the quality and safety of care that patients
and populations receive. This introductory chapter will
present an overview of the drivers of change in the
assessments used during clinical education, frameworks for
such assessments, criteria for choosing assessment methods,
elements of an effective faculty development effort, and the
need to shift to developmental assessment approaches using
competencies, Milestones, and Entrustable Professional
Activities (EPAs). Before moving on to fundamental issues of
assessment in a CBME world, we will first review some key
definitions and elements of CBME.
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Competency-Based Medical
Education
A focus on the educational process has now shifted to an
emphasis on what a physician is able to actually do at the end
of training and at important junctures during the training
process. Competencies have become a primary mechanism
for defining the educational outcomes of individuals.
Outcomes-based education starts with “the end in mind”; in
other words, a specification of the competencies (i.e.,
abilities) that are expected of a physician and are needed for
the healthcare tasks to be done. These educational outcomes
should determine the requirements for the content, context,
and structure of the curriculum; the selection and
deployment of teaching and learning methods; the site of
training; and the abilities needed of the teachers. Assessment
plays a central role in determining whether students,
residents, and fellows (or any learner in PGME) have
achieved the competencies that have been specified and
whether the educational program has been effective in
producing the desired outcomes. CBME highlights the
importance of integrating curriculum with assessment;
competencies are not independent abilities, but rather, all
competencies should be integrated as part of an overall
educational system and program of assessment. This change
in thinking and the need to assess the diverse and
interdependent competencies of the physician has been an
important factor in the development of new methods of
assessment, especially the work-based assessments covered
in detail throughout this book.
CBME is an outcomes-focused approach to and philosophy
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of designing the explicit developmental progression of health
professionals to meet the needs of those they serve. Among
its fundamental characteristics (see Table 1.1
) is a shift in
emphasis away from time-based programs based solely on
exposure to experiences such as clinical rotations in favor of
an emphasis on needs-based graduate outcomes, authenticity,
and learner centeredness.
18
,32
As defined by Frank and
colleagues, CBME is “an outcomes-based approach to the
design, implementation, assessment, and evaluation of
medical education programs, using an organizing framework
of competencies.”18 While outcomes are now the primary
driver, that does not mean educational structures and
processes are not important. The famous Donabedian
equation for quality, Structure × Process = Outcomes,
highlights that the desired outcomes depend on effective
structures and processes.
40
However, we are also learning
that the relationship between structure and process is quite
complex and nonlinear in its actual execution.41 Chapter 18
provides helpful guidance on how to embrace complexity as
part of program design and evaluation. Assessment is a
critical part of the complex interaction between structure and
process in an educational program.
Table 1.1
Fundamental Characteristics of Competency-Based Medical
Education
1. Graduate outcomes in the form of achievement of predefined desired
competencies are the goal of CBME initiatives. These are aligned with the roles
graduates will play in the next stage of their careers.
2. These predefined competencies are derived from the needs of patients, learners,
and institutions and organized into a coherent guiding framework.
3. Time is a resource for learning, not the basis of progression of competence (i.e.,
time spent on a ward is not the marker of achievement).
4. Teaching and learning experiences are sequenced to facilitate an explicitly
defined progression of ability in stages.
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5. Workplace curricula are individualized, with learning tailored to the learner’s
individual progression in some manner.
6. Numerous observations and focused feedback contribute to effective learner
development of expertise.
7. Assessment is planned, systematic, systemic, and integrative.
In 2019, Elaine Van Melle and colleagues, using a rigorous
stepwise process, identified and elaborated five core
components of CBME (Table 1.2, Fig. 1.2):
42
1. Competencies required for practice are clearly
articulated.
2. Competencies and their developmental markers are
arranged and sequenced progressively.
3. Learning experiences are tailored to facilitate the
progressive development of competencies.
4. Teaching practices promote the progressive
development of competencies.
5. Assessment practices support and document the
progressive development of competencies (i.e.,
programmatic assessment).
Table 1.2
Core Components Framework
Outcome
Competencies
Sequenced
Progression
Tailored
Learning
Experiences
CompetencyFocused
Instruction
Competencies
required for
practice are
clearly
articulated>.
Competencies
and their
developmental
markers are
sequenced
progressively>.
Learning
experiences
F>acilitate
. .> .
Teaching
practices
promote> . .
.
. . . the
developmental
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acquisition of
competencies.
From Van Melle E, Frank JR, Holmboe ES, et al. A core components framework
for evaluating implementation of competency-based medical education programs.
Acad Med. 2019 Jul;94(7):1002-1009. doi: 10.1097/ACM.0000000000002743.
FIG. 1.2 Core components framework for competency-based
medical education.
This core components framework (CCF) is increasingly
considered a useful characterization of CBME. Two aspects of
the CCF merit highlighting. First is the strong focus on
development; a recognition that educating health
professionals is an intensely developmental process. The CCF
is grounded in a mindset of growth and motivation and is
fully cognizant of the individualized trajectories each learner
will experience. Growth mindset—that is, a learner’s intrinsic
will to develop—should be the foundation for a significant
redesign of instructional methods, learning experiences, and
assessment practices.
42–46
Training programs should focus on
promoting and providing space for learner growth and
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development in the desired competencies through frequent
formative (lower-stakes) assessment that is rich in both
feedback and individualized coaching. Educators and
programs must therefore design assessment tools that
support the developmental trajectories of learners and
integrate them into a program of assessment, thus supporting
the learner’s professional development. Second,
programmatic assessment uses a systems lens as an essential
component, and Chapter 3
provides specific guidance on
creating, implementing, and maintaining programmatic
assessment.
Assessment is an essential activity (i.e., process) that can be
used to demonstrate outcomes of interest. This is not a new
insight—assessment has always been critically important in
any educational endeavor. However, the problems with
assessment in medical education, and generally all of health
professions education, have been long-standing and
persistent and include lack of direct observation of learner
performance and meaningful feedback; overreliance on
testing for assessment of medical knowledge; lack of
attention to other essential competencies that address our
graduates’ abilities to function effectively in our healthcare
systems, such as interprofessional teamwork and quality
improvement; and ineffective use of assessment methods and
tools by faculty, to name just a few. In the remainder of the
chapter, we will explore fundamental issues in assessment,
followed by how all programs can more effectively
operationalize competencies through Competency milestones
and EPAs and how these developmental assessment
constructs can support a program of assessment. Throughout
the chapter we will refer the reader to other chapters in the
book to help the reader create and revise their own program
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of assessment.
A Brief History of Assessment in
Medical Education
Through the early 1950s, physicians were assessed in limited
ways.47 Medical knowledge was evaluated with essays and
other open-ended question formats that were graded by an
instructor. Clinical skill and judgment were tested using an
oral examination that often required the student to go to the
bedside, gather patient information, and present it along with
a diagnostic list and treatment plan to one or more examiners
who asked questions. Because these were the only generally
accepted methods available, they were applied to most
assessment problems even if they were not completely
suitable to the task and were often unreliable. That may have
been acceptable at a time when supervisors had much more
control over the healthcare process, the therapeutic and
diagnostic armamentarium was much more limited, and
supervisors had natural checks for everything learners
reported. Healthcare is now far too complex to warrant this
type of “on-the-fly,” ad hoc approach. For example, length of
stay in hospitals has dropped dramatically, the number and
type of diagnostic and therapeutic tools has exploded, and
faculty have multiple competing responsibilities.
From that point to the present, there have been extensive
changes in the way assessment is conducted. Methods have
proliferated, as have the requirements for their appropriate
use. Much progress has been made in the assessment of
medical knowledge with a variety of written and computerbased techniques now offering reliable and valid results
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regarding the capability of learners (see Chapter 7). In the
past few decades, considerable gains have been made in
defining and enhancing the psychometric qualities of
standardized performance assessments that control for
context, such as objective structured clinical examinations
(OSCEs), particularly around their use for higher-stakes
purposes (see Chapter 6
). However, while assessments in the
context of caring for actual patients in clinical units (e.g.,
wards, operating theaters, ambulatory clinics) have vastly
improved, especially in the areas of patient care skills such as
medical interviewing, informed decision-making, and clinical
reasoning, much work remains, especially in competencies
such as interprofessional teamwork, care coordination, and
abilities in quality improvement and patient safety.
38
,48
Equally important, the methods that have been developed
to support clinical education often rely on faculty who are
inexperienced in their use, do not share common standards
or mental models of the competencies of importance, and
have not been trained to apply them in a consistent fashion.
In addition, faculty now experience substantial time
pressures, including caring for more patients, higher degrees
of comorbidity among hospitalized patients, and increasing
personal administrative responsibilities. Perhaps more
concerning are persistent findings that one of the principal
drivers of faculty assessment relates to their own clinical
skills (i.e., self as frame of reference or standard), with several
studies highlighting important deficiencies in practicing
physician clinical skills such as medical interviewing,
physical examination, and communication
49,50
(see Chapter
5). Finally, many faculty are also being asked to assess and
judge competencies, such as care coordination, quality
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improvement, use of clinical performance measures,
reflective practice, patient safety, and use of information
technology—areas in which they themselves were never
formally trained. Compounding this state of affairs has been
insufficient or ineffective faculty development approaches
and models to address these new clinical and educational
methods, although thankfully this situation is improving
51–54
(see Chapter 11).
Drivers of Change in Assessment
The increased public focus on the medical education
enterprise is important; medical education should always be
in service of individual patients, families, and the public.
Using a service logic can help educators develop assessment
programs that meet public, patient, and learner needs.55 Fig.
1.3 provides an example of a logic model based on
implementing competency milestones (discussed later in the
chapter). Many programs globally are implementing
curricular changes that embrace competencies and outcomes,
supported by improvements in technology, psychometrics,
and evolving work-based assessment approaches that
increasingly incorporate more qualitative techniques and
systematic judgment.
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