Wednesday, November 6, 2013

Evolution of Medical Education to Competency-Based Approaches: Can or Should Informatics Education Adopt Them?

There are major changes taking place in the education of physicians and other healthcare professionals. I have had the opportunity to be involved up close as OHSU undertakes a major transformation of its medical school curriculum.

As I work with our medical education leaders, and become familiar with the latest methods, jargon, and research, I ask myself whether informatics can or should adopt these approaches in our educational programs. In this posting I will review the methods and techniques being used in medical education, and in a subsequent posting will explore how these may be adapted by informatics education.

One of the major thrusts in medical education has been the move to competency-based medical education (CBME). A great deal of new jargon has emerged, the understanding of which is critical to read its literature [1].

Probably the biggest change being advocated is a transition from time-based to competency-based education [2]. This is based on the notion that our traditional time-based approach of students being "steeped" (like tea) in an educational program for a fixed period of time will result in their somehow emerging as competent practitioners. More recent thinking is that students acquire competencies at different rates from their fellow students, and there is no reason why all students should be forced into the same time period to attain them. This also has practical relevance in the need to increase the number of physicians in the US as the baby boomer population ages and more patients are brought into the healthcare system through healthcare reform.

Some aspects of these concepts are not new. For example, in the 1960s Bloom advanced the concept of "mastery learning" [3]. The idea behind mastery learning is that the variable changes from the traditional fixed time and measuring learning on a test to insuring that learning is complete and the variable being time, namely different time to master a subject for different students.

Another development in medical education in recent years has been the acceptance of a common taxonomy of competency domains [4]. This started with the six competency domains developed by the ACGME and ABMS, with 36 competencies delineated within them. More recently, the AAMC has added two additional domains and both added and refined the competencies to increase the total to 58.

An additional important development is the Next Accreditation System for graduate (post-medical school) medical education [5]. Central to this effort is the development of milestones (developmentally based, specialty-specific) that are achieved at five levels throughout medical school, residency, and advanced training or clinical practice. Seven specialties are launching milestones in 2013, with the remainder following in 2014 [6]. Training programs will be assessed based on the achievement of milestones by their trainees.

Another related concept to emerge is that of the entrustable professional activity (EPA), which is the notion that there are tasks or responsibilities that can be entrusted to a trainee once competence is achieved so that he or she can execute them without supervision [7]. EPA activities have been proposed for family medicine physicians [8], with others likely to follow.

These changes in medical education are also augmented by changes brought about by new technology. Two have been noted in particular: massive open online courses (MOOCs), which allow "flipped classrooms" and digital badges, both of which can create electronic means to validate milestones, EPAs, and other achievements [9]. Many other roles have been discerned as well [10-11].

Technology also foments other change in medical education. For example, the wedding of individuals to smartphones and tablets may have unintended consequences [12]. In addition, just as EHRs profoundly impact the workflow of physicians, they likewise impact the workflow of students [13]. Additional instruction may be required in reading and writing to the EHR [14] as well as its proper use in the patient-physician encounter [15-16]. Technology also impacts the role of the "master diagnostician," a teacher who also plays an outsized role in many academic medical centers [17].

The approach to educating physicians is clearly changing. The bulk of medical education leaders advocate an approach that changes the focus from one that is time-based to a more competency-based design. As such, there is no reason why medical education should last four years for everyone, and many aspects can be more individualized based on prior knowledge before medical school, learning systems, and other attributes of students.

It turns out that I have been using some of the above innovations in my own teaching, although I did not realize there were names for what I was doing. For example, in my introductory informatics course, taught in various venues as OHSU BMI 510 or AMIA 10x10, I sometimes teach the course "on campus." When I do this, it does not make sense to stand up and give lectures in the traditional sense. Instead, I use the "flipped classroom" approach of having students view the lectures before coming to class and then spending class time reviewing the material, answering questions, and discussing issues more deeply. (In online offerings of the class, these activities are carried out in discussion forums on our learning management system.)

In addition, for at least one class I teach, I use a variant of mastery learning. Another course I teach in our program is an elective course, BMI 536 - Evidence-Based Medicine. I believe that the best way to teach this topic is for students to repeatedly carry out the techniques of asking appropriate clinical questions and critically appraising the evidence until they get them right, i.e., have mastered them. They must do this before receiving a passing grade in the course.

In a future posting, I will explore whether this larger competency-based approach is appropriate to the education of informaticians, and if so, how we might implement it. I will also look at this from the standpoint of fellowships for the new physician subspecialty of clinical informatics.


1. Carraccio CL and Englander R, From Flexner to competencies: reflections on a decade and the journey ahead. Academic Medicine, 2013. 88: 1067-1073.
2. Hodges BD, A tea-steeping or i-Doc model for medical education? Academic Medicine, 2010. 85: S34-S44.
3. Kulik CC and Kulik JA, Effectivenss of mastery learning programs: a meta-analysis. Review of Educational Research, 1990. 60: 265-299.
4. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, and Aschenbrener CA, Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Academic Medicine, 2013. 88: 1088-1094.
5. Nasca TJ, Philibert I, Brigham T, and Flynn TC, The next GME accreditation system--rationale and benefits. New England Journal of Medicine, 2012. 366: 1051-1056.
6. Swing SR, Beeson MS, Carraccio C, Coburn M, Iobst W, Selden NR, et al., Educational milestone development in the first 7 specialties to enter the next accreditation system. Journal of Graduate Medical Education, 2013. 5: 98-106.
7. Ten Cate O, Nuts and bolts of enstrustable professional activities. Journal of Graduate Medical Education, 2013. 5: 157-158.
8. Shaughnessy AF, Sparks J, Cohen-Osher M, Goodell KH, Sawin GL, and Gravel J, Entrustable professional activities in family medicine. Journal of Graduate Medical Education, 2013. 5: 112-118.
9. Mehta NB, Hull AL, Young JB, and Stoller JK, Just imagine: new paradigms for medical education. Academic Medicine, 2013. 88: 1418-1423.
10. Triola MM, Friedman E, Cimino C, Geyer EM, Wiederhorn J, and Mainiero C, Health information technology and the medical school curriculum. American Journal of Managed Care, 2010. 16(12 Suppl HIT): SP54-SP56.
11. Anonymous, Health Professions Education: Accelerating Innovation Through Technology. 2013, The Blue Ridge Academic Health Group: Atlanta GA,
12. Wu R, Rise of the cyborgs: residents with smartphones, iPads, and Androids. Journal of Graduate Medical Education, 2013. 5: 161-162.
13. Ellaway RH, Graves L, and Greene PS, Medical education in an electronic health record-mediated world. Medical Teacher, 2013. 35: 282-286.
14. Han H and Lopp L, Writing and reading EHR documentation: an entirely new world. Medical Education Online, 2013. 18: 18634.
15. Pearce C, Dwan K, Arnold M, Phillips C, and Trumble S, Doctor, patient and computer--a framework for the new consultation. International Journal of Medical Informatics, 2009. 78: 32-38.
16. Pearce C, Arnold M, Phillips C, Trumble S, and Dwan K, The patient and the computer in the primary care consultation. Journal of the American Medical Informatics Association, 2011. 18: 138-142.
17. Dhaliwal G and Detsky AS, The evolution of the master diagnostician. Journal of the American Medical Association, 2013. 310: 579-580.

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