Ivan Silver

Competency-based medical education: theory to practice

Although competency-based medical education (CBME) has attracted renewed interest in recent years among educators and policy-makers in the health care professions, there is little agreement on many aspects of this paradigm. We convened a unique partnership – the International CBME Collaborators – to examine conceptual issues and current debates in CBME. We engaged in a multi-stage group process and held a consensus conference with the aim of reviewing the scholarly literature of competency-based medical education, identifying controversies in need of clarification, proposing definitions and concepts that could be useful to educators across many jurisdictions, and exploring future directions for this approach to preparing health professionals. In this paper, we describe the evolution of CBME from the outcomes movement in the 20th century to a renewed approach that, focused on accountability and curricular outcomes and organized around competencies, promotes greater learner-centredness and de-emphasizes time-based curricular design. In this paradigm, competence and related terms are redefined to emphasize their multi-dimensional, dynamic, developmental, and contextual nature. CBME therefore has significant implications for the planning of medical curricula and will have an important impact in reshaping the enterprise of medical education. We elaborate on this emerging CBME approach and its related concepts, and invite medical educators everywhere to enter into further dialogue about the promise and the potential perils of competency-based medical curricula for the 21st century.

A scoping review to improve conceptual clarity of interprofessional interventions

Interprofessional education (IPE) and interprofessional collaboration (IPC) have been identified in health education and health care as playing an important role in improving health care services and patient outcomes. Despite a growth in the amount of research in these areas, poor conceptualizations of these interprofessional activities have persisted. Given the conceptual challenges, a scoping review of the interprofessional field was undertaken to map the literature available in order to identify key concepts, theories and sources of evidence. The objective of this review was to develop a theoretically based and empirically tested understanding of IPE and IPC. A total of 104 studies met the criteria and were included for analysis. Studies were examined for their approach to conceptualization, implementation, and assessment of their interprofessional interventions. Half of the studies were used for interprofessional framework development and half for framework testing and refinement. The final framework contains three main types of interprofessional interventions: IPE; interprofessional practice; and interprofessional organization; and describes the nature of each type of intervention by stage, participants, intervention type, interprofessional objectives, and outcomes. The outcomes are delineated as intermediate, patient, and system outcomes. There was very limited use of theory in the studies, and thus theoretical aspects could not be incorporated into the framework. This study offers an initial step in mapping out the interprofessional field and outlines possible ways forward for future research and practice.

Competency-based continuing professional development

Competence is traditionally viewed as the attainment of a static set of attributes rather than a dynamic process in which physicians continuously use their practice experiences to “progress in competence” toward the attainment of expertise. A competency-based continuing professional development (CPD) model is premised on a set of learning competencies that include the ability to (a) use practice information to identify learning priorities and to develop and monitor CPD plans; (b) access information sources for innovations in development and new evidence that may potentially be integrated into practice; (c) establish a personal knowledge management system to store and retrieve evidence and to select and manage learning projects; (d) construct questions, search for evidence, and record and track conclusions for practice; and (e) use tools and processes to measure competence and performance and develop action plans to enhance practice. Competency-based CPD emphasizes self-directed learning processes and promotes the role of assessment as a professional expectation and obligation. Various approaches to defining general competencies for practice require the creation of specific performance metrics to be meaningful and relevant to the lifelong learning strategies of physicians. This paper describes the assumptions, advantages, and challenges of establishing a CPD system focused on competencies that improve physician performance and the quality and safety of patient care. Implications for competency-based CPD are discussed from an individual and organizational perspective, and a model to bridge the transition from residency to practice is explored.

Facilitated Reflective Performance Feedback: Developing an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content, and Coaches for Performance Change (R2C2)

Purpose To develop and conduct feasibility testing of an evidence-based and theory-informed model for facilitating performance feedback for physicians so as to enhance their acceptance and use of the feedback. Method To develop the feedback model (2011–2013), the authors drew on earlier research which highlights not only the factors that influence giving, receiving, accepting, and using feedback but also the theoretical perspectives which enable the understanding of these influences. The authors undertook an iterative, multistage, qualitative study guided by two recognized research frameworks: the UK Medical Research Council guidelines for studying complex interventions and realist evaluation. Using these frameworks, they conducted the research in four stages: (1) modeling, (2) facilitator preparation, (3) model feasibility testing, and (4) model refinement. They analyzed data, using content and thematic analysis, and used the findings from each stage to inform the subsequent stage. Results Findings support the facilitated feedback model, its four phases—build relationship, explore reactions, explore content, coach for performance change (R2C2)—and the theoretical perspectives informing them. The findings contribute to understanding elements that enhance recipients’ engagement with, acceptance of, and productive use of feedback. Facilitators reported that the model made sense and the phases generally flowed logically. Recipients reported that the feedback process was helpful and that they appreciated the reflection stimulated by the model and the coaching. Conclusions The theory- and evidence-based reflective R2C2 Facilitated Feedback Model appears stable and helpful for physicians in facilitating their reflection on and use of formal performance assessment feedback.

Faculty development for continuing interprofessional education and collaborative practice

This article proposes a framework for faculty development in continuing interprofessional education (CIPE) and collaborative practice. The framework is built on best practices in faculty development and CIPE. It was informed by local experience in the development, delivery, and evaluation of a faculty development program to promote capacity for dissemination of concepts relating to interprofessional education (IPE) and interprofessional collaboration (IPC) in health care environments. Interprofessional education has been demonstrated in clinical contexts to enhance interprofessional collaboration, patient care, and health outcomes. With curriculum design, teaching methods, and educational strategies in faculty development, it is possible to enhance the impact of IPE in clinical contexts. Faculty development activities themselves can model effective interprofessional education methods and practice. An IPE curriculum and teaching and education strategies are outlined. Strategic planning, including the application of a systems approach, attention to the principles of effective learning, and an outcomes-based curriculum design are recommended for the development of continuing IPE faculty development programs that enhance interprofessional collaboration.

Exploring mentorship as a strategy to build capacity for knowledge translation research and practice: protocol for a qualitative study.

BackgroundResearch funders, educators, investigators and decision makers worldwide have identified the need to improve the quality of health care by building capacity for knowledge translation (KT) research and practice. Peer-based mentorship represents a vehicle to foster KT capacity. The purpose of this exploratory study is to identify mentoring models that could be used to build KT capacity, consult with putative mentee stakeholders to understand their KT mentorship needs and preferences, and generate recommendations for the content and format of KT mentorship strategies or programs, and how they could be tested through future research.MethodsA conceptual framework was derived based on mentoring goals, processes and outcomes identified in the management and social sciences literature, and our research on barriers and facilitators of academic mentorship. These concepts will inform data collection and analysis. To identify useful models by which to design, implement and evaluate KT mentorship, we will review the social sciences, management, and nursing literature from 1990 to current, browse tables of contents of relevant journals, and scan the references of all eligible studies. Eligibility screening and data extraction will be performed independently by two investigators. Semi-structured interviews will be used to collect information about KT needs, views on mentorship as a knowledge sharing strategy, preferred KT mentoring program elements, and perceived barriers from clinician health services researchers representing different disciplines. Qualitative analysis of transcripts will be performed independently by two investigators, who will meet to compare findings and resolve differences through discussion. Data will be shared and discussed with the research team, and their feedback incorporated into final reports.DiscussionThese findings could be used by universities, research institutes, funding agencies, and professional organizations in Canada and elsewhere to develop, implement, and evaluate mentorship for KT research and practice. This research will establish a theoretical basis upon which we and others can compare the cost-effectiveness of interventions that enhance KT mentorship. If successful, this program of research may increase knowledge about, confidence in, and greater utilization of KT processes, and the quality and quantity of KT research, perhaps ultimately leading to better implementation and adoption of recommended health care services.

Structuring communication relationships for interprofessional teamwork (SCRIPT): A Canadian initiative aimed at improving patient-centred care

There is a growing movement in health care that advocates the use of interprofessional education to help deliver collaborative patient-centred care (Oandasan et al., 2004). For example, the Romanow Commission (2002) and the First Ministers’ Accord (Health Canada 2003) both stress the need for collaborative practice to help ensure that the quality of health care delivered to Canadians can be enhanced. Both reports identified that introducing interprofessional education within the health professional education system was the key to achieving this aim. Evidence of the effectiveness of interprofessional education suggests that it can generate a number of positive outcomes for professionals and for patients (Barr et al., 2005). However, at present, this evidence base is generally weak and fragmentary in nature (Zwarenstein & Reeves, 2006). To help generate a more informed understanding of interprofessional education and its potential impact on collaborative relationships and the delivery of patient care, the Canadian federal government has recently funded eleven projects across the country. This paper describes one of these projects based at the University of Toronto. The project involves the development of an intervention designed to improve interprofessional collaboration across three separate clinical settings: general internal medicine (GIM); primary care; and rehabilitation and complex continuing care. Each of these settings was selected as they represent key trajectories along which patients travel while receiving care in the Toronto Academic Health Science Network (TAHSN), the network of partnerships between the University of Toronto and its fully affiliated health services’ institutes. Journal of Interprofessional Care, January 2007; 21(1): 111 – 114

Self-Assessment and Continuing Professional Development: The Canadian Perspective.

Introduction: Several recent studies highlight that physicians are not very accurate at assessing their competence in clinical domains when compared to objective measures of knowledge and performance. Instead of continuing to try to train physicians to be more accurate self‐assessors, the research suggests that physicians will benefit from learning programs that encourage them to reflect on their clinical practice, continuously seek answers to clinical problems they face, compare their knowledge and skills to clinical practice guidelines and benchmarks, and seek feedback from peers and their health care team. Methods: This article describes the self‐assessment learning activities of the College of Family Physicians of Canada Maintenance of Proficiency program (Mainpro®) and the Royal College of Physicians and Surgeons of Canada Maintenance of Certification program. (MOC) Results: The MOC and the Mainpro® programs incorporate several self‐evaluation learning processes and tools that encourage physicians to assess their professional knowledge and clinical performance against objective measures as well as guided self‐audit learning activities that encourage physicians to gather information about their practices and reflect on it individually, with peers and their health care team. Physicians are also rewarded with extra credits when they participate in either of these kinds of learning activities. Discussion: In the future, practice‐based learning that incorporates self‐assessment learning activities will play an increasingly important role as regulators mandate that all physicians participate in continuing professional development activities. Research in this area should be directed to understanding more about reflection in practice and how we can enable physicians to be more mindful.

Advances in Psychotherapy Education

Acquiring expertise in psychotherapy is central to the professional development of psychiatrists able to employ a broad therapeutic repertoire in their clinical practice. This article reviews how postgraduate psychiatry programs address this important aspect of training. We present the results of a national survey of psychotherapy education in Canadian psychiatry residency programs. The results highlight significant advances over the past decade in curriculum, in teaching methods, and in evaluation. These include training in evidence-based, manualized, time-limited therapies such as cognitive-behavioural and interpersonal therapy, greater attention to evaluating competence, and integrating electronic technology. Trends and advances in postgraduate and continuing medical psychotherapy education programs are considered in association with principles of adult learning. Health education research endorses the provision of longitudinal training programs that integrate learning and practice. We discuss issues related to the development of expertise, the importance of educational communities of practitioners, and the importance of attending to both educational process and outcomes, with a view to more effectively translating psychotherapy practice guidelines into sustained improvements in practice behaviours.

Positioning continuing education: boundaries and intersections between the domains continuing education, knowledge translation, patient safety and quality improvement

Public and professional concern about health care quality, safety and efficiency is growing. Continuing education, knowledge translation, patient safety and quality improvement have made concerted efforts to address these issues. However, a coordinated and integrated effort across these domains is lacking. This article explores and discusses the similarities and differences amongst the four domains in relation to their missions, stakeholders, methods, and limitations. This paper highlights the potential for a more integrated and collaborative partnership to promote networking and information sharing amongst the four domains. This potential rests on the premise that an integrated approach may result in the development and implementation of more holistic and effective interdisciplinary interventions. In conclusion, an outline of current research that is informed by the preliminary findings in this paper is also briefly discussed. The research concerns a comprehensive mapping of the relationships between the domains to gain an understanding of potential dissonances between how the domains represent themselves, their work and the work of their ‘partner’ domains.