CBME implementation: Reflections of a former program director
By Dr. Adelle R. Atkinson, FRCPC
Adelle R. Atkinson, MD, FRCPC, University of Toronto.
For 15 years, it has been the privilege of my career to have had the opportunity to be the program director for a large Pediatric training program. When I recently stepped away, I was asked to reflect on my experience with competency-based medical education (CBME) implementation – the biggest change management initiative I had ever faced.
Program directors, by necessity, need to be great problem solvers. What I love about the role is the opportunity to mentor, guide, support and celebrate the ultimate successes of our residents. I believe in CBME and the benefits for patients and learners. The process of designing a developmental program of learning around competencies mapped to training experiences, supported by a comprehensive program of assessment, I believe will produce competent specialists who can provide comprehensive care to our diverse patient population. But how we implement the design into our programs is the challenge.
What advice would I give to someone, over coffee?
Being “in the weeds” with CBME implementation locally and nationally, has helped me to think differently about what supporting our learners in their journey looks like. And while it’s hard to distill such a seismic change into a mere few points, I have identified three areas I’d really like to focus on – my lessons learned, if you will – fostering a growth mindset, faculty development and resident development.
I hope these learnings resonate with you as you design your implementation strategy, and we embark on this monumental change together.
Growth mindset: Not just for learners
Individuals who believe their talents can be developed (through hard work, good strategies, and input from others) have a growth mindset versus those with a more fixed mindset (who believe their talents are innate gifts).
Fostering a growth mindset in our learners is currently a frequent topic of conversation in medical education. It is certainly integral to the success of CBME as it pertains to the learner embracing the feedback and coaching process, and being intentional, with mentorship, about their learning trajectory and growth. But it isn’t enough to nurture this only in our learners; we, as leaders, must role model a growth mindset, as must our competence committees, our hospital/departmental leadership and our systems. Only then, will the benefits of a growth mindset, and allowing oneself to be vulnerable, be possible in our context (Sawatsky et. al).
Faculty development: From understanding to engagement
Faculty development has always been an integral part of any implementation strategy for CBME, and I would argue that it may in fact be the key to success. There are different levels and types of faculty development for hospital/departmental leadership, educators, and front-line faculty, as examples. We need to ensure that everyone understands the goals of CBME, what it will look like, how it is different from what we have been doing, and we need to introduce new concepts and vocabulary.
It is critical to engage our faculty in this journey. It is not enough for them to just attend a session and understand what we are trying to do, we need them to buy in and to partner with us, especially in the context of workplace-based assessment where they will provide invaluable feedback and coaching to help our learners develop and ultimately achieve competence. It is important for faculty to partner with residents to create opportunities for feedback and coaching, as when it is largely resident-driven, there are some unintended consequences such as assessment fatigue, as well as over reliance on or avoidance of certain assessors, and anxiety.
Intentional and ongoing faculty development strategies can help mitigate these issues:
- telling stories – real examples of where CBME worked in the program, make it relevant for them;
- organizing friendly competition – letting them know how they are doing with respect to CBME expectations, compared to a larger group of faculty;
- encouraging them to stimulate the coaching/feedback conversation by discussing why it should not always be initiated by the resident – they are the content experts;
- having frequent check-ins to hear and act on, their feedback about the process;
- simplifying the process – e.g., a QR code they can scan to get right to the information they need such as EPAs or the assessment platform; and
- nurturing a growth mindset.
Resident development: Practical experiences help anchor information
Like faculty, preparing residents through an intentional resident development program is paramount to successful CBME implementation. When residents begin the program, it is timely to offer a tailored CBME orientation session that covers the advantages for our patients and for their learning, a detailed overview of what the program looks like for them, and what their responsibilities are, again in detail, with respect to actively engaging in the process. However, I have learned that this isn’t nearly enough though. While CBME makes sense to them in that moment, they don’t have any practical experiences in which to anchor the information. (And of course, orientation is a busy time with information overload, while they are trying to figure out where to get their ID badges and where the call rooms are!)
Residents need intentional and ongoing development:
- regular, frequent check-ins to see how things are progressing and to identify issues/questions that can be answered in real time – especially early on;
- frequent updates about they are doing while there is still time to catch up if they are behind;
- tips to help them identify high yield experiences relevant to the competencies;
- tips for partnering with faculty and highlighting what they need.
- ensuring transparency in the process (“not about them, without them”); and
- nurturing a growth mindset.
So, coffee time is over, at least for now, but the journey of learning how to successfully implement CBME will continue. It is paramount that we execute CBME with fidelity while ensuring that it adds value to our medical education systems, most importantly for our learners and our patients.