Nicholas Glasgow

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.

Characterisation of a highly sensitive troponin I assay and its application to a cardio-healthy population.

Abstract Background: Abbott Diagnostics have developed a new highly sensitive troponin I (hs-TnI) assay. We have assessed its analytical characteristics and applied the assay to a population of apparently cardio-healthy persons. Methods: We assessed imprecision, bias compared to the previous generation assay, matrix effects, and interferences and applied the assay to an apparently healthy population, deriving the 99th percentile limit of the distribution of values in reference populations for men and women separately. Results: The dynamic range of the assay was ranged from 0.5–50,000 ng/L (pg/mL). The 10% CV was at a concentration of 3.9 ng/L, and the 20% CV was at a concentration of 1.8 ng/L. The new and current version of the TnI assay were highly correlated [slope: 0.98 (95%CI:0.88–1.07), y-intercept:1.20 (95%CI:-2.35–4.75) r2=0.99]. The 99th percentile limit of the distribution of values in a reference population was different for males and females: for males 14.0 ng/L and for females 11.1 ng/L and at these concentrations the assay CV was 5.0%. TnI was detectable in nearly all patient samples from the healthy reference population (98.6%). Conclusions: This new hs-TnI assay is able to measure to an order of magnitude lower than the current generation TnI assay from the same manufacturer. With TnI being detectable in nearly all apparently healthy subject samples this suggests that TnI presence does not always indicate cardiomyocyte necrosis.

Entrustment Decision Making in Clinical Training

The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee’s development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis. Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article. The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors’ aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.

A Multicenter Study on Chronic Cough in Children Burden and Etiologies Based on a Standardized Management Pathway

BACKGROUND While the burden of chronic cough in children has been documented, etiologic factors across multiple settings and age have not been described. In children with chronic cough, we aimed (1) to evaluate the burden and etiologies using a standard management pathway in various settings, and (2) to determine the influence of age and setting on disease burden and etiologies and etiology on disease burden. We hypothesized that the etiology, but not the burden, of chronic cough in children is dependent on the clinical setting and age. METHODS From five major hospitals and three rural-remote clinics, 346 children (mean age 4.5 years) newly referred with chronic cough (> 4 weeks) were prospectively managed in accordance with an evidence-based cough algorithm. We used a priori definitions, timeframes, and validated outcome measures (parent-proxy cough-specific quality of life [PC-QOL], a generic QOL [pediatric quality of life (PedsQL)], and cough diary). RESULTS The burden of chronic cough (PC-QOL, cough duration) significantly differed between settings (P = .014, 0.021, respectively), but was not influenced by age or etiology. PC-QOL and PedsQL did not correlate with age. The frequency of etiologies was significantly different in dissimilar settings (P = .0001); 17.6% of children had a serious underlying diagnosis (bronchiectasis, aspiration, cystic fibrosis). Except for protracted bacterial bronchitis, the frequency of other common diagnoses (asthma, bronchiectasis, resolved without specific-diagnosis) was similar across age categories. CONCLUSIONS The high burden of cough is independent of children’s age and etiology but dependent on clinical setting. Irrespective of setting and age, children with chronic cough should be carefully evaluated and child-specific evidence-based algorithms used.

Achieving a balanced life in the face of chronic illness

The increasing prevalence of chronic disease is a driver of health system reform in most economically advanced nations. A consistent theme within these reforms is building greater patient-centredness into the health care delivery. This study aims to develop an in-depth understanding of the experience of patients and family carers affected by chronic illness that will be the basis on which to propose policy and health system interventions that are patient-centred. Participants struggled with the ongoing tasks of balancing their lives with the increasing demands and intrusion of chronic illness. Their attempts to achieve a balance were seriously hampered by fragmented services, complexity in navigating health services, relationships with health professionals and others, and co-morbidity. Future policy directions include designing models of care and infrastructure that enable patients and their family carers to balance life and illness, and aligning patient-centred care not only within health services but also with community and social support services.

A Cough Algorithm for Chronic Cough in Children: A Multicenter, Randomized Controlled Study

OBJECTIVES The goals of this study were to: (1) determine if management according to a standardized clinical management pathway/algorithm (compared with usual treatment) improves clinical outcomes by 6 weeks; and (2) assess the reliability and validity of a standardized clinical management pathway for chronic cough in children. METHODS: A total of 272 children (mean ± SD age: 4.5 ± 3.7 years) were enrolled in a pragmatic, multicenter, randomized controlled trial in 5 Australian centers. Children were randomly allocated to 1 of 2 arms: (1) early review and use of cough algorithm (“early-arm”); or (2) usual care until review and use of cough algorithm (“delayed-arm”). The primary outcomes were proportion of children whose cough resolved and cough-specific quality of life scores at week 6. Secondary measures included cough duration postrandomization and the algorithm’s reliability, validity, and feasibility. RESULTS: Cough resolution (at week 6) was significantly more likely in the early-arm group compared with the delayed-arm group (absolute risk reduction: 24.7% [95% confidence interval: 13–35]). The difference between cough-specific quality of life scores at week 6 compared with baseline was significantly better in the early-arm group (mean difference between groups: 0.6 [95% confidence interval: 0.29–1.0]). Duration of cough postrandomization was significantly shorter in the early-arm group than in the delayed-arm group (P = .001). The cough algorithm was reliable (κ = 1 in key steps). Feasibility was demonstrated by the algorithm’s validity (93%–100%) and efficacy (99.6%). Eighty-five percent of children had etiologies easily diagnosed in primary care. CONCLUSIONS: Management of children with chronic cough, in accordance with a standardized algorithm, improves clinical outcomes irrespective of when it is implemented. Further testing of this standardized clinical algorithm in different settings is recommended.

Challenges for co-morbid chronic illness care and policy in Australia: a qualitative study

BackgroundIn response to the escalating burden of chronic illness in Australia, recent health policies have emphasised the promotion of patient self-management and better preventive care. A notable omission from these policies is the acknowledgment that patients with chronic illness tend to have co-morbid conditions. Our objectives were: to identify the common challenges co-morbidity poses to patients and carers in their experiences of self-management; to detail the views and perceptions of health professionals about these challenges; and to discuss policy options to improve health care for people with co-morbid chronic illness. The method included semi-structured interviews and focus groups with 129 purposively sampled participants. Participants were people with Type 2 diabetes, chronic obstructive pulmonary disease and/or chronic heart failure as well as carers and health care professionals. Content analysis of the interview data was conducted using NVivo7 software.ResultsPatients and their carers found co-morbidity influenced their capacity to manage chronic illness in three ways. First, co-morbidity created barriers to patients acting on risk factors; second, it complicated the process of recognising the early symptoms of deterioration of each condition, and third, it complicated their capacity to manage medication.ConclusionFindings highlight challenges that patients with multiple chronic conditions face in relation to preventive care and self-management. Future clinical policy initiatives need to move away from single illness orientation toward strategies that meet the needs of people with co-morbid conditions and strengthen their capacity to self-manage. These patients will benefit directly from specialised education and services that cater to the needs of people with clusters of co-morbidities.

Proactive asthma care in childhood: general practice based randomised controlled trial

Abstract Objectives To assess the feasibility and effectiveness of a general practice based, proactive system of asthma care in children. Design Randomised controlled trial with cluster sampling by general practice. Setting General practices in the northern region of the Australian Capital Territory. Participants 174 children with moderate to severe asthma who attended 24 general practitioners. Intervention System of structured asthma care (the 3+ visit plan), with participating families reminded to attend the general practitioner. Main outcome measures Process measures: rates for asthma consultations with general practitioner, written asthma plans, completion of the 3+ visit plan; clinical measures: rates for emergency department visits for asthma, days absent from school, symptom-free days, symptoms over the past year, activity limitation over the past year, and asthma drug use over the past year; spirometric lung function measures before and after cold air challenge. Results Intervention group children had significantly more asthma related consultations (odds ratio for three or more asthma related consultations 3.8 (95% confidence interval 1.9 to 7.6; P = 0.0001), written asthma plans (2.2 (1.2 to 4.1); P = 0.01), and completed 3+ visit plans (24.2 (5.7 to 103.2); P = 0.0001) than control children and a mean reduction in measurements of forced expiratory volume in one second after cold air challenge of 2.6% (1.7 to 3.5); P = 0.0001) less than control children. The number needed to treat (benefit) for one additional written asthma action plan was 5 (3 to 41) children. Intervention group children had lower emergency department attendance rates for asthma (odds ratio 0.4 (0.2 to 1.04); P = 0.06) and less speech limiting wheeze (0.2 (0.1 to 0.4); P = 0.0001) than control children and were more likely to use a spacer (2.8 (1.6 to 4.7); P = 0.0001). No differences occurred in number of days absent from school or symptom-free day scores. Conclusions Proactive care with active recall for children with moderate to severe asthma is feasible in general practice and seems to be beneficial.

A temporal decline in asthma but not eczema prevalence from 2000 to 2005 at school entry in the Australian Capital Territory with further consideration of country of birth

BACKGROUND Asthma prevalence has declined in some countries over the past 10 years. Most reports have been based on population surveys conducted at two points of time in a given location. Comparisons across countries and time periods can be limited by differences in study methodology or disease diagnostics in different communities. Here, we examined trends in asthma prevalence using serial annual data and further examine the importance of country of birth. METHODS The source population has children aged 4-6 commencing school in the Australian Capital Territory from 2000 to 2005 inclusive. Over 80% of these children and their families completed a health questionnaire on asthma, other atopic disease and respiratory symptoms using some questions from the International Study of Asthma and Allergies in Childhood (n = 22 882). Current asthma has been previously validated against physician assessment in this setting. RESULTS The prevalence of current asthma declined (P < 0.001) but eczema ever increased (P < 0.001) from 2000 to 2005. The asthma decline was predominantly linear in form, and accompanied by a reduction in night cough and shortness of breath but not recent wheeze. Compared with Australian-born children, children from New Zealand and the United Kingdom had a similar prevalence of asthma, hay fever and eczema history. However, children born in other countries, such as Asia, generally had a lower prevalence of these disorders. The temporal trends for atopic disorders or respiratory symptoms did not differ for overseas-born compared with Australian-born children. CONCLUSION The decline in current asthma prevalence from 2000 to 2005 was linear in form and appeared uncoupled from trends in child eczema. Country of birth was associated with marked variation in atopic disorder prevalence. The similar temporal trends for Australian vs overseas-born children indicate that the factors underlying the asthma prevalence decline are unlikely to be only in the pre-natal period.

Identifying the policy implications of competency-based education

At their 2009 consensus conference, the International CBME Collaborators proposed a number of central tenets of CBME in order to advance the field of medical education. Although the proposed conceptualization of CBME offers several advantages and opportunities, including a greater emphasis on outcomes, a mechanism for the promotion of learner-centred curricula, and the potential to move away from time-based training and credentialing in medicine, it is also associated with several significant barriers to adoption. This paper examines the concepts of CBME through a broad educational policy lens, identifying considerations for medical education leaders, health care institutions, and policy-makers at both the meso (program, institutional) and macro (health care system, inter-jurisdictional, and international) levels. Through this analysis, it is clear that CBME is associated with a number of complex challenges and questions, and cannot be considered in isolation from the complex systems in which it functions. Much more work is needed to engage stakeholders in dialogue, to debate the issues, and to identify possible solutions.