15 Questions for
Peter Ferguson about
Competency by Design
Peter Ferguson
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Q1: What is your assessment
of the Competency
Based Orthopaedics
Curriculum (CBC)?
A: The initial form of
the Competency Based
Program was a pilot study
that was highly successful.
It then became mainstream
and we found
some components harder
to implement broadly. It
is now working phenomenally
well. We can now
document the feeling that we have had excellent results.
There is no change in the level of competence of the
applicants for the program, though the number has
been diminished by 20% because of the job market for
graduates.
Q2: What is the residents’ assessment?
A: The residents think that it is excellent. We are now
in the 6th year. We began with a subset of residents.
Seniors who missed it wished they had enrolled in the
CBC. The residents during the pilot phase were jealous
of those who were chosen to enter the CBC. Fortunately,
now all get it. The reason it was so popular with the
residents is because they develop technical expertise at
an earlier stage. The juniors expect to start hitting their
milestones at 4-5 months, e.g. the first milestone, such
as fix a hip fracture from beginning to end. There was
inefficient use of time in the older system and this has
been eliminated, especially the off-service rotations. The
program has new rotations, for example, instead of Ward
Medicine, the residents shadow the hospitalist at Mount
Sinai who manages medical and other hospital problems
for hip fracture patients.
Q3: Will other divisions be able to do that, like
Urology etc?
A: Unknown. There are some models they could adapt.
For example, there is, in addition to the hip fracture,
a musculoskeletal module led by Veronica Wadey. She
serves as organizer for them to attend clinics in infectious
disease, physiatry, genetics, and osteoporosis - with
preceptors. This is much more focused and effective than
the earlier ward medicine antecedent. Veronica is doing
an excellent job arranging this complex module.
Q4: What is the faculty assessment?
A: The faculty have realized that we won’t have “my
resident” at all times. The reasons for this include the
CBC plus the restriction of duty hours, and the now
accepted mismatch in the number of residents compared
to the number of surgeons. Our residency once had 60
residents. Currently, we have 48. They don’t work more
than they did, and so we use fellows and nurse practitioners.
We do not have physician assistants yet, though
this may eventually become part of the solution.
Q5: Some surgeons have asked: “how can they learn
to be doctors when they just zoom in and out and do
procedures?”
A: There is much more emphasis now on the intrinsic
CanMEDs roles, for example, on my service, oncological
orthopaedics, the role of communicator and professional
are carefully attended to. These are CanMeds roles illustrated
on the Curriculum map.
In their communicator role, we emphasize breaking
bad news such as the information that the patient has
cancer, or has metastases, etc. The professional role is
emphasized at the interdisciplinary oncology conference
and during interdisciplinary oncology care. There is a
multidisciplinary collaboration to divulge risk, to get
informed consent, etc. The metrics for all of these is
described in the Journal of Bone and Joint Surgery(1).
Q6: What is the best part of the program?
A: By far, it is repeated rigorous assessment. Our residents
were accustomed to being examined constantly in
school. Then they entered a five year program -without
formal assessment in the past. Now they know that they
will have a midterm exam six weeks into the rotation and
a 12 week final exam on all of the CanMeds roles and on
their technical skills. We don’t pass them if they are not
informed. In addition, the rigorous assessment helps us
identify dyscompetent or less successful residents early
on. In the past, these were not well identified early and
remediation did not begin as early as it does at present.
Q7: What are the problems with the CBP?
A: The number one problem is the logistics of scheduling.
All the residents are in it, and so we have abandoned
the open timeframe, where time was a variable
and knowledge a constant in our original formulation.
Time is also a constant now. If a resident stays behind
on oncology, the spine surgeons in the next rotation are
short. It is important that the residents know how to
run a service and this includes the timely arrival of the
resident and timely completion of the rotation.
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Q8: How do you remediate a resident?
A: It’s possible to tailor the program, especially in the
area of reading and concentrated learning, though we no
longer use the “tea steeping” technique of a longer time
until the rotation is fully understood. A second problem
is the extra burden on the faculty of doing assessment.
IPads and iPhones are helpful, but this is still a problem.
It has been helpful to give the residents responsibility
for the assessment. If the resident says “I have to do on
observed history and physical. Is it ok to do that with you
on Tuesday?” it is far more likely that this will be accomplished.
In addition, the resident or the administrative
staff sends a phone app assessment to the faculty which
can be quickly filled out. In the new version, we have
refocused on the importance of running a service rather
than fixing 30 hips. We have a more longitudinal and
less episodic procedural focus.
Q9: Should other divisions adopt the “Competency by
Design system”?
A: It gives a much more powerful tool to determine fitness
to practice. The legal and ethical implications are
important. In the past, it was level 5 evidence on fitness
to practice. In the future, all of us will be rigorously
tested throughout life. It’s good training to expect it.
Q10: Will it work for the other services?
A: Not in an identical form, but it should help. The
basic principles are that they can learn the craft early,
that inefficient training can be converted to earlier and
more focused skill training, and that evaluation had to
be improved. In the new system, evaluation is central.
The early technical skill training will be tailored to the
particular service. We do not have residents doing spine
surgery in their early rotations, but they do do arthroscopy
and certain standard operations, saving more
complex subspecialties for later. The other divisions will
need to work out the spectrum of activities for early
and late modules. We have a 2 week prep camp for all
residents, and that’s true throughout the Department.
In Orthopaedics, we also add a 2-3 week Ortho Prep
Camp that is focused on our specialty. Vascular and
Neurosurgery have a later Boot Camp during PGY1.
I was recently at Harvard and found that they have
adopted the boot camp directly from our model.
Q11: Why and how did all this get started?
A: Richard Reznick started the program off, asking
Ben Alman, who passed the responsibility on to Bill
Kraemer to do it. We are the source of this program.
The Royal College now anticipates that ENT/ Head and
Neck Surgery and Medical Oncology will be the next
programs to move into Competency by Design. It will
be harder in some specialties than others, for example
adolescent psychiatry might be difficult to put into
modules, but the suicide risk question is a technique that
people can learn and be tested on, and they will all learn
how to apply the lessons from the early experience with
Competency by Design.
Q12: What is your advice to residents?
A: Be accountable for your own education at an early
stage, don’t float along, or act like wallpaper, take charge
of your education, and validate your learning.
Q13: What is your advice to the faculty?
A: It’s not that different from how we have always done
it. The big difference for frontline teachers will be learning
to assess and record the educational process. The
tools are there, and they will simply need to be adapted a
little for burr holes or VATS. Professionalism only needs
the details of the cases to be altered. There is a CanMeds
OSCE once during the PGY3 year with remediation
applied on the basis of the OSCE and the evaluation
scores. Tim Dwyer, a new member of our division has a
particular interest in this educational focus. For example,
if a resident has done poorly on breaking bad news or
on triage questions, there are readings and exercises.
Eventually, other divisions will probably need some Tim
Dwyers in their program and may recruit toward that
goal. The Division administrators will need to learn
and they will probably need help. We have two skilled
administrators who can be helpful to them.
Q14: What about patient satisfaction?
A: They seem to be as satisfied as they always have been
in my observation. This is a good question to answer with
qualitative research. We currently ask the Head Nurse to
do a multi-source 360° on residents, using a standard form
summarizing the views of the other nurses. However, there
is room for more evaluation of this question.
Q15: How are the residents doing on their Royal
College exams?
A: All of the residents passed their Foundation exam from
the first time, and 7 of 9 were advanced to take their fellowship
exam after 4 years. I personally like the idea of a 4 year
core followed by a one year Transition to Practice year, for
example, in a mini-practice under faculty supervision. That
may be a development for the future.
M.M.
REFERENCES
(1) Ferguson PC, Kraemer W, Nousiainen M, Safir O, Sonnadara
R, Alman B, Reznick R. Three-Year Experience with an Innovative,
Modular Competency-Based Curriculum for Orthopaedic Training,
J Bone Joint Surg Am. 2013; 95: e166(1-6) |