The Transition to Competency by Design for All Surgical Specialties

Ron Levine

Competency-Ba s e d Medical Education (CBME) involves implementing outcomes-driven assessment to ensure physicians possess the knowledge and abilities they need for every stage of their career. The Royal College is ushering in a new era of CBME in Canada with the introduction of Competency by Design (CBD). Canada’s medical education is rooted in a time-based model. The plan for CBD is to shift to a plan in which more emphasis is placed on regular assessment of performance.

We are still in the time - based apprentice model, which turned out good surgeons, so we know that the system works. For excellent, very good and good residents our training program is quite satisfactory. It is not so good for the fair or lower achieving residents. I was a Program Director in Plastic Surgery for 16 years. I sat at the end of residency with each candidate one on one. The assumption was that if you got enough and saw enough, you were competent. This was based on no, or very few assessments - too much was assumed. For the resident who is not doing well, earlier formal assessment can identify the difficulty and a remediation plan can be implemented. This can be done at a much earlier stage and we do not have to wait until a resident is in their senior year of training. The other advantage of CBD is that it is possible that the resident will be able to complete training in a shorter period of time. I like CBC because it reduces subjectivity and the notion that maybe one more rotation will fix the problem.

Orthopaedics at the University of Toronto is the gold standard for competency by design teaching and assessment. A lot of time and money went into its development and at the present time, all residents in Orthopaedics are in a competency based curriculum. The Royal College has mandated CBD for all specialties. All specialties and subspecialty programs in Canada will adopt CBD in gradual phases. All disciplines divided into 7 cohorts will begin their transition to CBD each year until 2022. The first cohort is medical oncology and otolaryngology. The second cohort includes two surgical programs, specialties, Urology and Surgical Foundations.

CBD for each surgical specialty will be designed at the national level by the discipline’s specialty committee (program directors, clinician educators, continuing professional development experts and invited guests) who will collaborate with the Royal College to develop CBD for that specialty. They will assign milestones and Entrustable Professional Activities (EPAs) to each stage of training. They will determine competency based assessment practices and prepare faculty for CBD. CBD will look different for each specialty and will depend on what the specialty committee designs. The Postgraduate Medical Education Office at the University of Toronto, under the lead of Dr. Susan Glover-Takahashi, will help in the implementation of CBD of each specialty in the Department of Surgery.

M. M. with contributions from Ron Levine