A new era in Canadian medical education is underway as it switches from a primarily time-based learning system to one where core competency levels, dubbed “milestones,” must be achieved and demonstrated by students before they move on. The system is being phased in over the remainder of this decade, with a few residency specialties testing the new approach this fall as part of a pilot program. Although not yet officially announced, those specialties in the pilot program could be anesthesiology, medical oncology, pediatric surgery and plastic surgery.
It’s not a simple task to bring change to the entire profession, nor will it happen overnight.
The competency-based approach will be used for the “whole continuum of medical education, so that includes medical students – what we call undergraduate medical education – as well as residency education. As well, it should be related to our continuing medical education,” said Geneviève Moineau, president and chief executive officer of the Association of Faculties of Medicine of Canada, the umbrella group for Canada’s 17 medical schools. She stressed that the medical schools “are really committed” to the change, pointing out that for some time now, in order to be accredited, the schools must show that their curriculum will produce students who are competent in certain skills in order to graduate.
“It brings home the importance that the competency should shape the education … this puts the competencies at the forefront, which from a pedagogical standpoint makes more sense,” Dr. Moineau said.
The main driver for the profession’s change is the Royal College of Physicians and Surgeons of Canada, one of two bodies that set standards for the medical profession. The Royal College is responsible for about 80 specialties while the College of Family Physicians – also committed to the competency approach – sets the standards for the family practice specialty.
Although the Royal College has had competency at the core of its CanMEDS medical education framework since 1995, it describes the coming change as “transformational and fundamental.” It has involved – and will continue to involve – national consultation.
“Medicine is just catching up to some university programs that have used competency-based standards for a while,” said Jason Frank, one of the architects of the project in his position as director, specialty education, policy and standards at the Royal College. Other programs that include competency standards in some form or another include nursing, engineering, accounting and teaching, among others. U.S. President Barack Obama’s higher education reform proposals, unveiled recently, also focus on competency-based learning.
Dr. Franks points out that while doctors will complete their residencies as experts in their specialty, they must also have progressed through milestones in a number of other domains including communication, collaboration, health advocacy, ethics and practice management. Delivering bad news to a patient and the patient’s family, for example, is part of a doctor’s job. It involves a number of skills that trainee doctors must master. “Med students may be aware of that when they first start, but when they graduate from the MD degree program they should be able to deliver bad news under controlled conditions with supervision,” said Dr. Frank, giving an example of milestone levels. “By the time they leave residency or postgraduate training they have to be able to do it independently.”
The medical schools say they are well positioned for the advent of milestones. For example, they still use exams to test knowledge but they are also using what’s known as “Observed Clinical Skills” formats that give the “opportunity to watch students, usually with standardized patients, perform certain tasks related to patients – like history taking, physical examinations or other tasks,” said Dr. Moineau. (Standardized patients are individuals who act as patients for the purposes of training.) She said that in the second half of medical school, the students spend most of their time in clinical situations and that is also key to evaluating them as future professionals.
“If a medical student is not behaving in a professional manner, they do not graduate from medical school. Long ago that wasn’t necessarily the case. We’ve been able to demonstrate the importance of the competencies in their professionalism, in their communication skills, in their collaboration skills, so that has been a great improvement in our assessment of medical students.”
Dr. Moineau says, as the milestone system is more fully adopted, theoretically it will be possible for some medical students to finish sooner. She gives as an example a practising registered nurse who has returned to study medicine, who might have an advantage over a student entering medical student directly from an undergraduate program. “We’re very happy to have both of those candidates, but the reaching of certain milestones might be easier for that experienced nurse.”
The medical schools think the bigger problem may turn out to be funding. Right now, medical education is funded by the provinces based on the number of years of training, so moving to a milestone system could mean standing the current funding model on its head since some students might be able to develop their competencies in three years while some may need five.
However, Dr. Frank doesn’t think funding at the residency training level will be a problem. “We think the existing funding envelope will be just fine and we’re not asking governments for more money.”
Another aspect of the program is the lifelong e-portfolio that will contain the competencies of every physician. The first e-portfolios will roll out this November and are designed to go from the start of medical school to retirement from practice. “When someone logs in, their whole career is available. This is going to help facilitate lifelong learning,” said Dr. Frank, who is an emergency physician.
“The ultimate version will not only be tailored to the individual but will use social media tools built into it to see what their peers are doing in the same discipline,” he said. “So, I log in as an emergency physician and I record some evidence of my learning and I’ll see what my peers are learning, not individually but as a group. That’s a powerful steering effect.”
The project has stimulated debate about medical education within the profession, exposing some philosophical differences. Some are opposed to the coming changes, citing what’s called the tea-steeping theory where one needs time to process a new skill even after demonstrating competency in it, and that doing it a dozen times more is a good thing.
“Perhaps the juste milieu, in fact, is both,” said Dr. Moineau. “But, as I say, the development of the competency-based curriculum will not be the challenge. It will be the implementation from a logistical, financial and philosophical perspective.”