Emancipating educationAbraham Lincoln Presidential Library

Springfield, IL

September 28, 2013Felix Ankel, MD

Watson

Human

Curate

From Hierarchies to Networks

Community of Practice

Community of practice

Create

All,We recently had a case where an intern, when asked by the nurse taking care of a patient with a NSTEMI, said it was okay for the patient to go to the bathroom off monitor. You guessed it; the patient subsequently was found in arrest in the bathroom. In our reactionary culture, some of our faculty are advocating for all decisions to go through the 3rd year resident and to make sure the intern doesn’t make decisions that adversly affect patient care. So, the questions for the collective:

• Do you have a formal statement about what interns are allowed to do?

• If not formally, do you have a process of what interns are allowed to do?

• Are the nurses the “determiners” of who to go to?

The “Miracle” of Medical Education

Slide credit Eric Holmboe

•Autonomy•Complexity•Context

Autonomy

Able to take full responsibility for going beyond existing

standards and creating own interpretations

From the professional standards for conservation, Institute of Conservation (London) 2003, Based on the Dreyfus model on skill acquisition

Complexity

Holistic grasp of complex situations, moves between

intuitive and analytical approaches with ease

From the professional standards for conservation, Institute of Conservation (London) 2003, Based on the Dreyfus model on skill acquisition

Context

Sees overall “picture” and alternative approaches; vision

of what may be possible

From the professional standards for conservation, Institute of Conservation (London) 2003, Based on the Dreyfus model on skill acquisition

The Light at the End of the Tunnel…

1. Explosion of medical knowledge: need to re-conceptualize competence

2. The growth of performance measurement: quality and safety indicators, patient experience, etc.

3. Shift to interprofessional care and changing scope of practice

4. Advances in cognitive science: expertise, retrieval practice, situated and distributed cognition, etc.

5. Critical role of “context” – complex adaptive systems

6. Growing public pressure to change7. HIT/Clinical Decision Support

…Is a Freight Train

Slide credit Eric Holmboe

Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010

Why CBME: 21st Century Healthcare

Next Accreditation System

22

Continuous Oversight &

Improvement Emphasis

Milestone Reporting

(semi-annually)

Case LogsResident &

Faculty OpinionsProgram &

Institutional Information

Uniformity of Milestone Reporting• 5 levels of proficiency

– Novice, Beginner, Competent, Proficient, Expert• Level 4 - The ABEM certification standard

– By definition where an individual should be at time of graduation

• Level 5 - Attained after practice• Narrative anchors• Based on knowledge, skills and abilities (KSAs)• Balance between

– Deconstruction (microtasks)– Integration (complex performance)

Reliabilities across methodsslide created by Cees van der Vleuten 2012

TestingTime inHours

1

2

4

8

MCQ1

0.62

0.76

0.93

0.93

Case-BasedShort

Essay2

0.68

0.73

0.84

0.82

PMP1

0.36

0.53

0.69

0.82

OralExam3

0.50

0.69

0.82

0.90

LongCase4

0.60

0.75

0.86

0.90

OSCE5

0.47

0.64

0.78

0.88

1Norcini et al., 19852Stalenhoef-Halling et al., 19903Swanson, 1987

4Wass et al., 20015Petrusa, 2002

Carraccio C, Wolfshtal SD, Englander R, Ferentz K, Martin C. 2002. Shifting paradigms: from Flexner to competencies. Acad Med 77(5):361-367. p 362.

Structure- and process-based

Competency-Based

Driving Force: Curriculum Content Outcome

Driving Force: Process Teacher Learner

Path of learning Hierarchical Non-hierarchical

Responsibility for content Teacher Student and teacher

Goal for educational encounter Knowledge acquisition Knowledge

application

Program completion Fixed time Variable time

What are the characteristics of a highly functioning CBME system?

“This has resulted in the world’s first pilot of a competency (as opposed to time) based orthopedic training program”

Macrotrends• From hierarchies to networks (CoP)• From individual experts to wisdom of crowds (CCC)• From knowledge to competency (CBME)• From carrots and sticks to autonomy, mastery, and

purpose (Dreyfus and Dreyfus)• From function to design (CLER visit)• From argument to story (narrative anchor)

Drivers and themes for innovation

• Curation and Aggregation

• Communities of Practice

• Creation of Tools

• Assessment• Time• Money

Competency by design

Thank you

• Brad Gordon• Rob Cooney• Jessie Nelson• Derek Schmidt• Jason Frank• Ali Jalali• Cees Van der Vleuten

• Tom Nasca• Mary Healy• David Griffen• Julie Kirkham• Eric Holmboe