The value of CBD and its impact on the future of medicine

August 11, 2020 | Author: Guest post

By Dr. Roy Kirkpatrick

** I recognize how significantly COVID-19 is impacting all aspects of our profession, but I also thought you might appreciate reading an article that addresses something outside of this pandemic.  As a general surgeon serving rural communities for more than 30 years, I see real value in Competence by Design and this is why I believe Fellows everywhere should be aware of this new training system. 

Dr. Roy Kirkpatrick

Dr. Roy Kirkpatrick (Submitted photo)

Medicine is constantly changing and evolving.  When I graduated from medical school in 1977, the use of technology was much less common. For example, we diagnosed appendicitis without any imaging at all. There was less pressure on system resources, which seemed to afford us the opportunity to be more focused simply on good patient care.

The system then and the system today may be different, but the motivation for why I chose medicine and why someone today would choose medicine are likely the same. Medicine has always been, and will always be, about our patients.

Working in a rural setting, many of my patients are also my neighbours and it has been a privilege to serve my community for more than three decades. I see this same passion in the Northern Ontario School of Medicine (NOSM) residents I work with today; they integrate the competencies of all seven CanMEDS Roles, delivering compassionate care to their patients.

Competence by Design makes residents more adaptable

On July 1 of this year, my discipline (General Surgery) officially launched under the Competence by Design training model. You’ve probably heard rumblings about Competence by Design — some of you are now actively teaching residents in this new system and some (2,000+ of you) were involved in the design and development of it.

When I look at this new model, I see the preservation of what has always made our system exceptional. Foundationally, it is what we have always done: produce the highest set of educational standards that guide us to deliver world-class doctors. But Competence by Design is also evolving the system to make residents more nimble and adaptable.  For example, the final stage of training focuses on residents’ ability to practice independently and further develop clinical courage.

Moving away from high-stakes feedback, embracing continuous improvement

Competence by Design breaks training down into several different stages. At each stage, there are discipline-specific CanMEDS entrustable professional activities (EPAs) and milestones. I see this as one of the greatest strengths of this new model because, instead of a few high-stakes evaluations, residents consistently receive feedback on their performance.

The philosophical difference is that the focus no longer lies in the assessment of learning, but now focuses on assessment for learning. This includes coaching that provides specific actionable suggestions for improvement. This helps ensure that if gaps exist, they are identified as early as possible.

With the sweeping move to distributed education, Fellows across the country, including those in rural areas, are becoming more involved in medical education. Through NOSM, we regularly have third-year medical students and residents working closely with us in Hunstville. This exposure to intermittent learners provides the chance to coach residents. The evaluations are quite simple; they are easily managed through an app or on a computer screen, and by design should only take a couple of minutes.  This is our chance to transfer our knowledge and expertise to the next generation of specialists.

Ensuring the best care for all Canadians, including rural populations

There are a lot of incredible benefits to working and serving Canadians outside of urban areas. As a general surgeon in a rural setting, every day is different. In a single shift, I can perform an abdominal surgery, do a skin graft and perform a C-section.  As I mentioned earlier, I know many of my patients. I knew them before they were on the operating table and I often have the pleasure of seeing them outside the hospital setting, living healthy lives years down the road.

For many of us working in rural areas, we chose to work in these communities because we wanted to be hands-on with our patients and didn’t necessarily want to be involved in teaching. I was one of those Fellows but then the opportunity with NOSM came about and it completely changed my perspective.

I became involved with NOSM in the late 2000s and, at first, I was concerned about my ability to teach and evaluate the learners. Through Competence by Design, I have a framework that is practical and easy, where I have been able to move away from the high-stakes, one-off evaluations, to a model where the frequent and ongoing feedback is more aligned with coaching.  

Paying it forward

As Fellows, we feel indebted to those who educated us.  For the Royal College to continue to be the leader in speciality medical education and care in the years to come, we all have an important role to play. I am proud of this new system. It was built by Fellows from across Canada and it has been an honour to be part of its implementation. Whether you are a clinical scientist, an urban specialist or a Fellow working in remote and isolated areas, Competence by Design can help address the challenges you are facing today.

Competence by Design not only prepares residents for the realities of 21st century health care, but it also ensures we continue to meet the highest standards for our profession. As we pass the torch forward to future generations, we can have confidence that each evaluation we provide is fostering the development of the next generation of specialists.

At some point in our lives, either we or our loved ones are going to be in the care of a doctor who trained under this new system. I have confidence that this new model is building doctors whom we can continue to trust with the care of those most dear to us.

Dr. Roy Kirkpatrick has been practising General Surgery in Huntsville, Ont., since 1987. He provides intermittent locum coverage in Moose Factory, Ont., and has worked for the Canadian Red Cross and Doctors Without Borders.  Among other things, he is the chair of the Division of Surgery at the Northern Ontario School of Medicine, a specialist representative on the Society of Rural Physicians of Canada’s Rural Road Map Implementation Committee, and a member of Royal College Council.  He is also an avid outdoorsman, proud husband and father, and in 2019 was promoted to adoring grandfather.


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Alfred Sisto | March 12, 2022
CBD becoming the international design of education to respond to the challenges facing primary and secondary care.
John Hinchey | January 1, 2022
I have just recently learned about Dr Kirkpatrick and am very impressed with his accomplishments.I was chief of general surgery at the Montreal General when In the mid nineteen eighties I was asked to supply a locum surgeon to relieve the surgeon in Iqaluit so He might have a well deserved holiday.Andy Hreno agreed to do two weeks if I would do two weeks.I continued to do so after I retired and didn’t stop until I was in my early eighties.I was thrilled to learn that Dr Kirkpatrick has continues the tradition-I loved my time there and the challenges it provided.