Achieving Competency-Based, Time-Variable Health Professions Education Catherine R
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ACHIEVING COMPETENCY-BASED, TIME-VARIABLE HEALTH PROFESSIONS EDUCATION HEALTH TIME-VARIABLE ACHIEVING COMPETENCY-BASED, CATHERINE R. LUCEY, MD R. LUCEY, CATHERINE Achieving Competency-Based, Time-Variable Health Professions Education Proceedings of a conference chaired by Catherine R. Lucey, MD June 2017 Atlanta, Georgia ISBN# 978-0-914362-34-0 February 2018 This monograph is in the public domain and may be reproduced or copied without permission. Citation, however, is appreciated. Lucey, C. R. Achieving Competency-Based, Time-Variable Health Professions Education. Proceedings of a conference sponsored by Josiah Macy Jr. Foundation in June 2017; New York, NY: Josiah Macy Jr. Foundation; 2018. All photos by Jared Gruenwald Photography. Accessible at: www.macyfoundation.org Achieving Competency-Based, Time-Variable Health Professions Education Proceedings of a conference chaired by Catherine R. Lucey, MD Atlanta, Georgia June 2017 Edited by Teri Larson Published by Josiah Macy Jr. Foundation 44 East 64th Street, New York, NY 10065 www.macyfoundation.org February 2018 CONTENTS Preface ......................................................................... 7 Introduction ..................................................................11 Conference Agenda ........................................................14 Conference Participants . 20 Conference Conclusions and Recommendations .....................23 Commissioned Paper Time-Variable Training in Medicine: Insights Derived from the Literature and from Examples in Practice .........................53 Commissioned Paper Great Expectations: Competency-Based Medical Education from Reality to Vision .....................................................113 Case Study The University of Wisconsin-Milwaukee: Flexible Option for BSN Completion. 137 Case Study Describing the Journey and Lessons Learned: Implementing a Competency-Based and Time-Independent Undergraduate Medical Education Curriculum. 157 Case Study Education in Pediatrics Across the Continuum (EPAC): Realizing the Dream of Time-Variable, Competency-Based Advancement in Medical Education . .179 Highlights from the Conference Discussion ......................... 201 Selected Bibliography .................................................... 237 Biographies of Participants ............................................. 241 4 5 6 PREFACE GEORGE E. THIBAULT, MD The 2017 Macy Conference, Achieving Competency-Based, Time-Variable Health Professions Education, was perhaps the most ambitious of our conferences in the past decade because it addressed fundamental issues in the structure and pedagogy of all health professions education across the full continuum from beginning learners to experienced practitioners. We were emboldened to take on such an ambitious topic because advances in both theory and practice support a robust discussion of the pros and cons of radically changing our approach to educating the next generation of health professionals. We also felt an imperative to respond to the sense that our current educational enterprise is not fully meeting the needs of the patients we serve or of the learners we are educating. The planning for a Macy Conference begins a full year before the conference, when we convene an interprofessional planning committee of educators and thought leaders to define the scope of the conference, draft a charge for the conferees, decide on commissioned papers and case studies, and draw up a list of potential conferees. We were blessed with a particularly experienced and insightful group chaired by Catherine Lucey, MD. The conferees assembled in June in Atlanta, Georgia, were a diverse group of educators from nursing, medicine, pharmacy, and higher education with a mix of theoretical, clinical, measurement, and regulatory backgrounds. The two commissioned papers and three case studies formed the platform to begin the spirited and in-depth discussions that then went on for two and one-half days in plenary sessions and thematic breakout groups. There were two major concepts that were the drivers of the discussion. The first concept is that of competency-based education. It was agreed that the competencies required for successful practice are derived from the needs of the patients and the public to be served. This realization changes the perspective of the processes of curriculum development and assessment. The second major concept is that of time as a resource in the educational process rather than a fixed 7 endpoint. Embracing this concept would enable faculty and learners to allocate time as needed to accomplish the educational goal of competency. Such an approach would also require a change in learners’ attitudes about the value of feedback, which would become the means by which learners progress to the next stage. All this will require developing a partnering relationship between faculty and learners, creating new and exciting roles for faculty and promoting a model for lifelong learning. While becoming very excited about the enormous potential of this new model for health professions education, the conferees were also aware of the challenges in making such an ambitious paradigm shift. Consensus was reached on specific recommendations in five domains: (1) redesigning all elements of the learning environments; (2) creating a true continuum of education from novice to practitioner; (3) developing and implementing a robust assessment system; (4) developing and using enabling technologies; and (5) evaluating outcomes of learners, programs, and patients. There also was consensus that these innovations could not all be done at once, but that it is imperative that the process of change begin now. Early adopters can help pave the way for those that follow. In the end, there was a unanimous feeling that these changes would be an essential part of creating a reformed health care system that better meets the needs of our patients. The conferees reaffirmed the importance of health professions education in improving the health of the public. The success of a conference such as this depends upon many individuals. The conferees all gave of themselves unstintingly with energy, insight, and mutual respect. The planning committee facilitated the smooth running of the conference and the writing of the final report. All this was brilliantly led by Catherine Lucey as chair and staffed by Yasmine Legendre of the Macy Foundation. This is both an exciting and an unsettling time in health care and health professions education. We all left the conference with a renewed sense of commitment to seize this moment to better align education with societal needs and real optimism that we have the tools and the will to do so. George E. Thibault, MD President, Josiah Macy Jr. Foundation 8 9 10 INTRODUCTION CATHERINE R. LUCEY, MD CONFERENCE CHAIR The Institute for Healthcare Improvement Leadership Alliance has articulated its vision for the radical redesign of the health care system to achieve the following goals: care better than we’ve ever seen; health better than we’ve ever known; cost we can all afford—for every patient, every time.1 When we achieve these goals, each patient who interacts with the health care system, whether for prevention, diagnosis, or treatment, will engage with professionals who are fully committed to, and measurably capable of, providing care that is safe, high-quality, equitable, efficient, effective and patient-centered.2 Achieving this ideal health care delivery system begins with a carefully engineered educational continuum in which every health professional advances through the stages of formal education and into practice only when they have demonstrated mastery of all competencies needed to: • provide compassionate and expert care to a diverse population of patients; • function optimally within contemporary health care systems and interprofessional teams; and • embark on a long career of lifelong learning and continuous assessment. Our current time-bound, fragmented health professions educational systems do not yet fulfill this promise. Fortunately, advances have occurred in our pedagogical understanding of how health professionals attain expertise, alongside the tremendous biomedical advances of the past century. Application of educational theory to the complex workplace learning experiences of health professionals suggests that a revolutionary shift from course- and clerkship-based, time-bound education to competency-based, time-variable education is needed to bring us closer to the ideal system that meets the needs of our learners, our faculty, and, most importantly, our patients.3,4 11 Competency-based, time-variable (CBTV) education begins by designing educational programs with an explicit and relentless focus on the needs of patients and society for improved health and health care. In CBTV, health professions educational institutions continuously refine the competencies required of their graduates by monitoring evolving health care issues of patients and society; integrating advances in biomedical, social, and behavioral sciences; and leveraging opportunities provided by technological progress. Achieving this level of societal responsiveness requires a greater degree of adaptability in curricular planning and execution than our current educational institutions have demonstrated.5,6 CBTV education posits that the amount of responsibility and level of supervision assigned to each learner in the clinical environment must be determined by measuring competency, not by tabulating the number of