In the last decade of the 20th century, competency garnered a great deal of attention in medical education. Spurred by broader educational trends, many medical educators, administrators, and accrediting agencies shifted their educational emphasis from inputs to outputs, focusing less on what educators teach and more on what learners should be capable of doing. This fostered a great deal of discussion regarding which competencies physicians at various levels of training should be able to demonstrate. What should all graduating fourth-year medical students be able to do? What additional abilities should radiology residents be able to demonstrate by the end of their training?
In 1999, the Accreditation Council of Graduate Medical Education endorsed new core competencies, expecting residency and fellowship programs to demonstrate their educational effectiveness in each of the following six areas: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Residents and fellows must demonstrate that they have achieved competence in each of these areas, and programs must prove that they are not only teaching but assessing and documenting learner performance.
Also in 1999, the Indiana University School of Medicine adopted a competency-based curriculum, consisting of the following nine competencies: effective communication; basic clinical skills; using science to guide diagnosis, management, therapeutics, and prevention; lifelong learning; self-awareness, self-care, and personal growth; the social and community contexts of health care; moral reasoning and ethical judgment; problem solving; and professionalism and role recognition. Students are expected to achieve intermediate knowledge and skill in all areas by the end of the first 2 years, then progress to proficiency in all by the end of the third year, and finally to demonstrate advanced knowledge and skill in three of these areas by the end of the fourth year.
Developing, implementing, and evaluating competency-based curricula at both the graduate and postgraduate levels of medical education provides a number of insights. At our institution and others, we have talked with learners and identified a number of opportunities for improvement in competency-based medical education. Broadly speaking, these insights may be divided into three aspects of the educational program: curriculum, instruction, and assessment. By gaining a deeper appreciation of learners’ perspectives on the role of competencies in each of these core educational missions, we can take steps to enhance the quality of competency-based education at all levels.
Doing so can also help address some of the most frequent criticisms leveled at competency-based education, many of which turn out to be directed less at the concept of competency itself than the particular means by which it is pursued. For example, competency-based education is frequently criticized as behavioristic and atomistic; that is, it tends to focus on observing learners’ actions instead of how they think and feel. Furthermore, this approach tends to be perceived by some as fragmented, failing to treat the learner as an integrated whole. By understanding better how learners perceive competency-based education, we can do a better job of engaging the character of the whole learner.
Curriculum
First, it is essential that learners understand the value of each of the competencies. Many learners are unable merely to list the competencies that are supposed to constitute the framework for 4 or more years of their education. What percentage of residents can name the six Accreditation Council for Graduate Medical Education competencies? If learners do not know them, there is a relatively strong case to be made that competencies do not, at least in learners’ minds, represent the foundation of their education. Some learners also speak of the competencies as a set of hoops through which they must jump, articulating little or no appreciation for why these competencies, as opposed to others, have been chosen.
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Instruction
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Assessment
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